Neurodevelopmental Program Intake Form

Neurodevelopmental Program Intake Form

Autism Genes
To get the most from your call with Dr Heather, we ask you to take the time to complete this comprehensive intake form please. Once you have watched the entire Q & A video, and submitted this form, reception will schedule your 15-minute call with Dr Heather, to discuss how we can help your child and answer any additional questions you may have.
Patient Full name*

First NameMiddle NameLast Name
Date of Birth *

MonthDayYear
Date
MaleFemale
Parent / Guardian full name*

First NameLast Name
Relationship to Patient *
Parent / Guardian Email*
example@example.com
Parent / Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
So your practitioner can get a full understanding of key areas and behaviours please upload a 15 second video of your child.
Please upload a 15 second video of your child

Cancelof
Home situation
YesNoNot Applicable
If yes, please provide further information
YesNoNot Applicable
If no, please briefly describe the situation
YesNoNot Applicable
Diagnosis
ASDADHDRETT SyndromeDevelopmental delaysPDDNOSNo diagnosisOther
If other, please list here
Intellectual Status
Diagnosed with intellectual impairmentBelow averageAverageAbove averageGenius
Birthing
VaginalC-SectionFull termPrematureMother received antibiotics at birthBaby received antibiotics at birthBaby received vaccines at birthExclusively breast fedBreast fed then bottle fedUnknown, child was adopted or fostered
Vaccinations
Fully up to date with childhood vaccination scheduleHas had some of the childhood vaccinations but stoppedHad a number of catch up vaccinations on the same dayAccidentally double vaccinatedNoticed regression after any childhood vaccinations - high pitched screaming, lost eye-contact, lost speechHad COVID vaccine/sNot vaccinated at allOther
Current Testing
Microbiome TestOrganic Acids Test (OAT)Neural Zoomer Plus / PANDAS / Strep / Immune TestingMycotoxin TestingToxin DetectionDNA TestingDone no testing at allOther
Speech
Non-verbal, may mumble and make noisesSituational mutism - will speak, at least a little in some settingsUses PECS or similar pictorial communication systemUses SPELLER systemSays up to 3 words in a rowSpeaks in phrasesEcholaliaSpeaks in sentencesCan initiate a conversation and converse back and forthCan understand youCan express needs and wantsSpeaking fluently, language is developed and age appropriateBilingualOther
Feeding Habits
Picky eater, eats limited foodsWill eat favoured foods, cooked a particular wayDifficulty chewingDifficulty swallowingTube fedLoves dairy - milk, yoghurt, icecream or cheeseStrong preference for crunchy foodsStrong preference for soft foodsStrong preference for white foodsStrong preference for carbohydrates - bread, pasta, cereal, cookies, chipsStrong preference for sweet foods - fruit, sweets, chocolate, cake, biscuitsWon't allow foods to touch on the plateMeat only, no vegetablesFruits only, no meat or vegetablesVegetables only, no meatNot fussy, will eat anything put in front of them
Current Diet
Standard junk food diet, eg. breads, biscuits, pasta, chicken nuggets, pizza, soft drink, fruit, milk etc - little vegetables if anyMeat, vegetables, fruits, breads, eats everything well, no specific dietOrganicGluten freeDairy freeGAPS / Specific carbohydrate dietVegetarianVeganLow FODMAP / SIBOKetogenicPaleoAnti-Candida dietLow oxalate dietFeingoldOtherNone of the above
GERD / Reflux Screening
Has known refluxRegurgitation or spitting up of food after eatingSometimes vomits after eatingPersistent coughing, clears throat frequently, especially at nightTooth enamel been eroded by gastric acidBurpingBad breathDifficulty swallowingFalls asleep propped up in bedNone of the above, I see no evidence of refluxOther
Bowel Habits
ConstipationDiarrhoeaDiarrhoea and constipation (mixed)Bowel moves well, every day, no issuesUse laxativesBloatingUndigested food in stoolsMucus in stoolsSticky stools, use too much toilet paperFoul smelling bowel movementsExcessive gasBurpingPresses tummy over things like arms of couchesToilet trainedStill in night nappiesNot yet toilet trained
Parasite Screening
DiarrhoeaBloatingStomach pain crampsUnexplained weight lossItching around the anus, especially at nightMucus or blood in the stool?Recent overseas travel, particularly places like India or BaliAccidental drinking of untreated water from a river, lake or stagnant waterFrequent play in dirt or sand and putting hands in their mouth, particularly if you have petsPets are not dewormed frequentlyPreviously diagnosed with a parasitic infectionNone of the above, I see no symptoms of parasites
Immune System Screening
Frequent runny noseDark under eye circles, puffy eyesCheeks and ears flush red for no reasonRecurrent ear infectionsCatches every coldSinus infectionsWartsCold soresSore throatsAsthmaEczemaHives / RashesPica (eats inedible things like dirt)Never gets sickOther
Allergy Screening
YesNo
What allergies or intolerances are you aware of?
Candida / Yeast Screening
Sugar cravingsWhite tongueLaughing inappropriatelyCheeks bumpy with red patchesRectal or vaginal itchingCracking or peeling feet or handsAthlete's footRed ring around the anusSpaced out / foggyDry / flaky skin on face / scalpToe walkingNone of the above
Mould Illness / CIRS Screening
Had / still has exposure to mould in the home or school environment. This may be due to flooding or leaky roof tiles etc.Memory impairment "brain fog"Coughing, wheezing or shortness of breathChronic sinus congestion / infectionsFrequent sneezing or postnasal dripRed watery eyes or blurry visionExcessive thirstIncreased urinary frequencyWeak, joint pain, stiffness, aches and painAppetite swingsFatigueNight sweatsAbdominal pain / bloatingMood changes, more anxietyWorsening behaviours, aggression, self-injury, repetitive behavioursTrouble falling asleep or staying asleepHeightened sensitivity to light or soundClumsiness or balance difficultiesWorsening food intolerancesNone of the above
PANS / PANDAS Screening
Frequent Strep infections, sore red throat or feversFrequent viral infectionsSudden onset or worsening of OCD symptomsSevere anxietyFrequent mood swingsIrritability, aggression, oppositional behavioursSudden tics or worsening of ticsMotor difficultiesDeteriorating handwritingSudden hyperactivityMore frequent urinationHeightened sensory issuesSleep disturbances, insomniaSudden decline in school workNone of the above
Tic Screening
Sudden brief involuntary muscle movements or jerksSudden brief involuntary vocalisations or soundsRepetitive blinking, snorting or coughing, touching the nose, smelling objectsHand flappingTip toe walkingPicking at skin until rawHas Tourette SyndromeNone of the above, I see no evidence of tics / stimming
Seizure Screening
YesNo
OCD Screening
Rigid or inflexible routines, insistence or samenessPersistent intrustive thoughtsFear eg. of germs, harm, doing / saying something wrongPreoccupation with perfectionRepetitive actions to reduce anxiety eg. excessive handwashing, flicking light switchesRituals, eg. lining up toysRepeatedly tapping or touching objectsNeed for symmetry and order, includes touching things with left and then right handSpending excessive amounts of time grooming, dressingExcessive checking eg. locks, doorsObsessive worry over things unlikely to happenIntense meltdowns if rituals are disruptedNone of the above, I see no evidence of OCD
Behaviour
Has difficulty following rulesArgumentativeEasily angered and frustratedRegular meltdownsDestructive with furniture, walls, household itemsPhysically aggressive with family membersPhysically aggressive with classmates, teachersNegative behaviour to get attentionBullies or bosses other childrenTrouble with group playIs rejected by others or avoidedPrefers to be aloneMeticulously lines up blocks or toysWould play video games all the time if allowedAnxiousDepressedA "runner" (runs away impulsively)None of the above
ADD / ADHD Screening
Difficulty sitting stillFidgetyHigh energy, on the goRestless, roams aroundDifficulty concentratingTouches everythingEasily excitedTalks excessivelyNone of the above
Sleep
Falls asleep easilyDifficulty falling asleepDifficulty falling asleep occasionallyOnce asleep, stays asleep all night and body is peaceful and calmStays asleep all night but body is restless, tosses and turns (covers all torn up)Awakens maybe once a night, and goes right back to sleepFrequent night awakenings, does not go back to sleep easilyNot unusual to wake up at an extremely early hour eg. 3amSleeps more than normalSleeps less than normalNight terrorsTakes melatoninTakes pharmaceutical medication for sleepNone of the above
Mitochondrial Screening
Poor muscle toneCurved back / slouching when sittingDifficulty knowing self in spaceTires easilyHand eye co-ordination is poorTrouble with pencil grip / poor handwritingPoor expressive and receptive speech"Crashes" when they get sick or dehydratedSedentaryNone of the above
Sensory
Sensitive to noiseSensitive to lightsSensitive to smellsSensitive to textures - foods, finger paintSensitive to tags and seamsSensitive to crowdsRocking, flapping, spinning, finger twirlingFinds pressure calmingNone of the above
Signs of Zinc Deficiency
Has white spots on fingernailsSkin issues, acne, psoriasisCanker soresHeightened sensory defensivenessDoesn't particularly like red meatGets a stitch in the side while runningDoesn't get to sleep wellCan tend to be anxiousNone of the above
Signs of Magnesium Deficiency
Muscle cramps or twitchesDifficulty sleepingEats a lot of sweet foodsSalt cravingsSighingChews on toys, clothingNone of the above
Dental
Child allows you to brush their teethBrushes their own teethRefuses to allow any tooth brushingUsing flouride toothpasteUsing natural xylitol based toothpasteChild allows you to flossTolerates regular visits to the dentistChild has fillingsChild has no fillingsNone of the above
Medications
Please list current medications
Natural Supplements
YesNo
List of supplements
Your Top 5 Goals
List the top 5 goals you are hoping to achieve for your child:*
Discovery Method
Word of mouthFacebookInstagramEmailWeb searchOther social mediaReferred by professionalNone of the above
Referrer Details
If you were referred by a professional, what is their name please so we can thank them.
Research Data
Autism Genes is always looking to improve the lives of children and adults with Autism, ADHD and other developmental delays along with gut issues and chronic illness though furthering research in these areas. We would like your permission to use completely de-identifed data for research purposes. To clarify you/your child will not be identifiable from this data in any way, it is simply the testing data itself that we are asking for permission to use. Do you give permission for us to use this de-identified data.*

YesNo
IntellxxDNA genomic reports are non-diagnostic.IntellxxDNA reports are non-refundable and cannot be transferred to another patient.IntellxxDNA is not a lab. The patient’s specimen will be processed at third-party CLIA/CAP certified lab anonymously.Patients cannot mail their specimen from the state of New York. Patients will be instructed to mail their specimen from outside of New York, for example, New Jersey, or Connecticut.N/A
Should be Empty:

Neurodevelopmental Program Intake Form

Home situation

Diagnosis

Intellectual Status

Birthing

Vaccinations

Current Testing

Speech

Feeding Habits

Current Diet

GERD / Reflux Screening

Bowel Habits

Parasite Screening

Immune System Screening

Allergy Screening

Candida / Yeast Screening

Mould Illness / CIRS Screening

PANS / PANDAS Screening

Tic Screening

Seizure Screening

OCD Screening

Behaviour

ADD / ADHD Screening

Sleep

Mitochondrial Screening

Sensory

Signs of Zinc Deficiency

Signs of Magnesium Deficiency

Dental

Medications

Natural Supplements

Your Top 5 Goals

Discovery Method

Referrer Details

Research Data