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.
  • Date of Birth *
     - -
  • Patient Gender*
  • Format: (000) 000-0000.

  • So your practitioner can get a full understanding of key areas and behaviours please upload a 15 second video of your child.

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  • Home situation

  • Does the child divide time living between two different homes?*
  • Are both parents onboard with any necessary changes like removing gluten / grains, dairy, and adding a supplement regime?*
  • Are there any difficult family situations which may hinder treatment (eg. court orders, chronically ill parent, new baby)?*

  • Diagnosis

  • Does the child have a diagnosis of any of the following?*

  • Intellectual Status

  • How would you currently rank your child intellectually?*

  • Birthing

  • Please check appropriate boxes:*

  • Vaccinations

  • Please check appropriate boxes:*

  • Current Testing

  • Have you conducted any of the following testing in the last 6-12 months?*

  • Speech

  • Describe the child's speech:*

  • Feeding Habits

  • What are your child's feeding habits?*

  • Current Diet

  • Are you following any particular diet at the moment?*

  • GERD / Reflux Screening

  • Do you observe any reflux symptoms?*

  • Bowel Habits

  • What are your child's bowel habits?*

  • Parasite Screening

  • Does the child have any of these parasite symptoms?*

  • Immune System Screening

  • Does your child ever have immune issues?*

  • Allergy Screening

  • Does your child have any allergies or intolerances?*

  • Candida / Yeast Screening

  • Does your child ever show these behaviours?*

  • Mould Illness / CIRS Screening

  • Does your child have any of the following?*

  • PANS / PANDAS Screening

  • Does your child's behaviour suddenly change for the worse with infections, particularly Strep throat?*

  • Tic Screening

  • Does your child ever have Tics / Stims (without infections)?*

  • Seizure Screening

  • Does your child have seizures?*

  • OCD Screening

  • Does your child have any of these OCD symptoms?*

  • Behaviour

  • Behaviour difficulties:*

  • ADD / ADHD Screening

  • Do you observe the following ADHD symptoms in your child?*

  • Sleep

  • What are your child's sleep patterns?*

  • Mitochondrial Screening

  • Do you observe any of the following?*

  • Sensory

  • Is your child displaying any of these behaviours or sensitivities?*

  • Signs of Zinc Deficiency

  • Do you observe any of these signs of zinc deficiency?*

  • Signs of Magnesium Deficiency

  • Do you observe these signs of Magnesium deficiency?*

  • Dental

  • Dental issues*

  • Medications

  • Natural Supplements

  • Are you taking any natural supplements?*

  • Your Top 5 Goals

  • Discovery Method

  • Where did you hear about us?*

  • Referrer Details

  • 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.*
  • If you choose to proceed with the program and wish to undergo DNA testing, please provide your informed consent to all four of the following statements from IntellxxDNA. Simply check eachof the 4 relevant boxes below to agree to the statements.*
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