Date

Name

First Last

Date of Birth

Age :

Current Grade / Degree earned

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If minor, Parent/Guardian Names

First Last

Sibling Name(s):

Age(s):

Home No.

Cell No.

Adult Patients: To the best of your ability complete form with the known information about your mother’s pregnancy, your birth and your early life. “Baby” refers to you and your early life.
Parents of patient: This developmental history provides information that will be used to develop an individualized treatment plan for your child. Please answer with as much detail as you can remember.
All:Please check multiple boxes when necessary, circle items that pertain to your answers, or write out your responses.

1. Who referred you for this evaluation?

Name

First Last

2. Parents are

Natural

Foster

Adoptive

3. What are the most pressing current concerns?

4. Is there a history of traumatic events?

Yes

please state:

5. vaccinated

Yes

at what age was first vaccine received?

Any vaccine reactions?

Yes

describe:

7. Has a diagnosis been identified? (i.e. Dyslexia, Dyspraxia, ADHD, ADD, Anxiety, Depression, specific health issue, etc.)

Yes

please state:

8. What other testing has been done?

9. What other interventions/supports have you tried?

10. List prescribed medication and reason for medication:

Medication

Reason For Medication

BIRTH & EARLY DEVELOPMENT

1. Was IVF used to support conception?

Yes

2. Any known medical problems during pregnancy with patient?

High blood pressure

Yes

Preeclampsia

Yes

Preterm labor

Yes

Depression, Stress, Anxiety

Yes

Infection

Yes

Gestational Diabetes

Yes

Other:

Yes

What?

3. Did Mother smoke or vape while pregnant with patient?

Yes

4. Did Mother drink alcohol while pregnant with patient?

Yes

5. Was patient born

At term

Early

Late

weeks

6. Birth:

Vaginal-Hospital

Vaginal-Home

Planned Cesarean

Emergency Cesarean

7. Birth Process: Place a star by any birth phase that was concerning. State concern (ie: slow, quick, extra support, etc)

a. Pre-Labor

b. Pushing

c. Crowning

d. Exiting

e. Afterbirth

8. Birth weight:

Length:

Apgar Score if known:

9. At birth, were there any physical, sensory (visual, auditory, tactile, etc), feeding, emotional or movement concerns?

Yes

explain:

10. Was eye contact made between baby and mother within the first few minutes of life?

Yes

11. Was baby placed on mother’s belly to crawl to breast within the first few minutes of life?

Yes

12. Was there difficulty latching, sucking, feeding, keeping food down?

Yes

13. Was baby colic?

Yes

14. Was baby breast fed?

Yes

15. Is there a history of very active or demanding behavior as an infant and/or child?

Yes

16. Is there a history of very quiet behavior as an infant and/or child?

Yes

17. Is there a history of violent rocking motions that caused the crib to move?

Yes

18. Is there a history of banging head against floor or walls, or hitting head with hands

Yes

19. Age of learning to walk?

20. Did baby crawl on tummy (commando crawling) before creeping on hands and knees

Yes

21. Creeping (on hands and knees- often thought of as crawling)

creeped on hands and knees for more than 4 months

creeped on hands and knees for less than 4 months

scooted on bottom

preferred rolling rather than creeping

 did not creep on hands and knees, stood up and walked

22. Was there a delay in motor development?

Yes

23. Age of speaking 2–3-word phrases:

(typically this occurs around age 2)

24. Before age 3, was there an illness with high temperatures, convulsions, or seizures?

Yes

please give details:

26. Was there a regression in development following an illness?

Yes

27. Was there any sign of infant/childhood eczema?

Yes

28. What age did sucking a pacifier, thumb, clothing, blanky stop?

29. At what age was day and night-time potty training achieved without any accidents?

30. Is there a history of motion sickness, car sickness, or fear of heights?

Yes

Learning

1. Is there any history of learning difficulties in the family?

Yes

2. Were there problems learning to read?

Yes

3. Were there problems learning to write?

Yes

4. Difficulty learning to tell time from an analog clock (2nd grade skill)?

Yes

5. Difficulty learning to ride a two-wheeled bicycle?

Yes

6. Poor eye-hand coordination (catch ball, typing, zipping, etc.)?

Yes

7. Poor gross motor coordination (skipping, swimming, hitting a ball etc)?

Yes

8. Has difficulty waiting quietly, sitting still, or standing still?

Yes

9. Makes numerous mistakes when copying from a book?

Yes

10. Writes the wrong thing, or reverse letters when writing?

Yes

11. Overreacts/ loses attention often.

Yes

12. Frustrated/anxious with work/school?

Yes

13. Needs educational support at school?

14. Needs adaptions or other support to perform at work?

Yes

15. If support is needed, list support or accommodations:

Gastro-Intestinal/Epigenetics/ Nutrition

1. Any known gastrointestinal problems?

Yes

2. Any stomach pains?

Yes

3. Are there unusual bowel patterns?

Yes

4. Is diarrhea, dry stools, or constipation common?

Yes

5. Are there skin problems:

Acne

Rash

Eczema

Dry patches

Small bumps

Dermatitis

Other

6. Has a food sensitivity and/or nutritional needs assessment been performed?

Yes

7. Has Nutrigenomics testing been done? (Genetic based brain/gut health support)?

Yes

8. Takes supplements?

Daily

Occasionally

Does not take

fish oil

multivitamin

List other supplements:

9. Is there excessive thirst?

Yes

10. Are mood swings associated with hunger?

Yes

11. Do symptoms get worse if there is more than a 2-3 hours interval without eating?

Yes

12. Are there food cravings: sweets, breads, starches?

Yes

13. Are there any foods or food additives that alter behavior?

Yes

specify:

14. List favorite foods:

15. Dietary needs/preferences:

16. Current Diet:

Excellent

Good

Fair

Poor

Breathing Profile

1. Has asthma

Yes

induced by:

Exercise

Infections

Animals

Dust

Mold

Third Choice

Foo

2. What is the primary way of breathing?

I am not sure

inhale & exhale through nose

inhale through nose & exhale through mouth

inhale through mouth & exhale through nose

inhale & exhale through mouth

very quiet/ shallow breather

very audible breather

3. Known allergies:

4. Suffers from:

Vision

1. Has had a developmental vision exam?

Yes

2. Approximate date of last comprehensive vision exam

3. Has participated in a program of optometric vision therapy?

Yes

a. prescribed by Dr.

b. Approximate date of vision therapy program

4. Vision skill concerns:

Auditory

1. Do you suspect problems processing auditory information?

Yes

2. Has an audiologist performed an evaluation?

Yes

3. Has difficulty following directions?

Yes

4. Gets distracted from sounds?

Yes

5. Is oversensitive to sounds?

Yes

6. Covers ears?

Yes

7. Gets confused when listing to conversations?

Yes

8. Confuses similar sounding words?

Yes

9. Needs directions repeated?

Yes

10. Has difficulty following multistep sequential instructions?

Yes

11. Has history of speech problems?

Yes

12. Leaves out beginning, middle, or end sounds when talking?

Yes

13. Has articulation challenges, stutters, or hesitates when speaking?

Yes

14. Has high pitch, flat or monotonous voice?

Yes

15. Has underdeveloped vocabulary?

Yes

16. Has difficulty reading aloud?

Yes

17. Has poor reading comprehension?

Yes

18. Has difficulty spelling?

Yes

19. Has fluency issues with reading, writing, or speaking?

Yes

20. Has had auditory training/ therapy?

Yes

i. which program?

ii. Did the auditory processing program use bone conduction?

Yes

Behavioral and Social Adjustment

1. Has:

2. List any concerns regarding emotional state:

3. Has there been evaluation by a psychologist or psychiatrist?

Yes

4. List or check skills you are hoping to develop/improve

Other:

Any Additional Comments:

REFLEX INTEGRATION: New Patient Questionnaire

BIRTH & EARLY DEVELOPMENT

Learning

Gastro-Intestinal/Epigenetics/ Nutrition

Breathing Profile

Vision

Auditory

Behavioral and Social Adjustment

North Royalton

Beachwood

Westlake