Name
First Name
Last Name
Parents
Mother's First and Last Name
Father's First and Last Name
Email
example@example.com
Address
Street Address
City
State
Postal Code/Zip
Country
Phone Number
All appointments will be via phone call. If you live within the US, I will call the listed number above directly. If you are international, would prefer a phone call via WhatsAPP or Facebook?
Gender
Please Select
Male
Female
Date of Birth
-
Year
-
Month
Day
Date
Child's Weight
Were you referred to me by another parent, if so, who?
Mother's health (please list any past or current health issues)
Father's health (please list any past or current health issues):
List any medications or vaccinations mother received during pregnancy:
List any complications during pregnancy:
Gestational age at delivery (how many weeks of pregnancy):
Childbirth: vaginal or cesarean?
List any complications during or after delivery:
Was your child breast fed?
If yes, for how long?
If your child was formula fed, what formula was used?
Was your child fully vaccinated according to schedule?
Did your child display any obvious or adverse reactions following any vaccinations? Please explain
How was your child's first year of life, did they meet developmental milestones appropriately?
Has your child received any antibiotics, required a hospital stay, or had any procedures performed? Please list each, including medications and anesthesias used.
Did your child ever experience a regression? If so, when, and what skills were lost?
When did you start to have concerns about your child's development? What actions did you take?
Where have you resided since pregnancy? List all locations, and approximate year each home was built. Do you have any concerns of exposure to mold?
What traditional therapies has your child participated in and were they helpful?
What alternative or biomedical interventions have you tried?
If you have implemented any biomedical interventions or supplements, were there any you found to be particularly beneficial? Please explain.
If you have implemented any biomedical interventions or supplements, were there any that your child did poorly with or did not tolerate? Please explain.
Have you worked with any functional medicine or MAPS doctors, homeopaths, nutritionists, etc? If so, please list.
Have you had any diagnostics or lab work performed? Please list each, including year completed. Please email all previous labs after submitting this intake form to: Becky@ASDhealthcoach.com
How is your child's sleep?
How are your child's digestion and bowel habits? Please list frequency and texture of bowel movements.
How is your child's diet, are they currently on any restrictive diets or trialed any in the past? Are they a picky eater? Please list what foods they primarily eat.
Does your child have any self stimulatory or repetitive behaviors? If so, please list below.
How is your child's social interaction and engagement? Are they affectionate?
How is your child's expressive language, speech, and communication? Please explain.
How is your child's receptive language, cognition, and understanding? Are they able to follow single or multi-step directions?
How are your child's motor skills? Please describe fine and gross motor capabilities or challenges.
Is your child in school? If so, what grade? Are they receiving any accommodations or do they have an IEP? How are they doing in school? Please explain.
What are your child's biggest strengths?
What are your child's biggest challenges?
What are your goals; what would you like to gain by working with me?
Are there any challenges that could prevent you from being successful in implementing treatment? (financial, logistical, etc)
Is there any additional information you would like me to know that would be helpful for me in understanding your child?
Do you have any specific treatments or protocols in mind that you would like guidance with?
Please list all of your child's CURRENT supplements, including dosages:
What is your child's school/therapy schedule?
Can your child swallow capsules? Which forms of supplements do you prefer to use: liquids, capsules, chewable tablets, gummies, etc?
I agree to read the following forms: Parental Agreement, Waiver & Financial Responsibility:
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