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Name: *
Home Phone Number:
Cell Phone Number: *
Email: *
Best way to reach you:
Age: *
Gender: Female Male
Referred by:
If yes, who is your clinician?
Occupation: *
Employer:
Marital Status: * Single Married Divorced Widowed
Name of Spouse:
List names of children/siblings, age, sex and any concerns in the area below.
Emergency Contact Name: *
Emergency Contact Phone Number: *
Relationship: *
Other explanation:
Other explanation:
Reason you are here:
Previous treatments for this complaint:
Other complaints or problems:
If yes, describe:
If yes, describe:
If yes, describe:
Comments:
If yes, for how long?
Comments:
If yes, describe:
If yes, describe:
If yes, please list name(s) and date(s) of last visit:
4. Current medications/drugs being taken:
5. Nutritional supplements you are taking:
7. Have you suffered any serious childhood diseases, had any operations, or other medical problems?
8. Have you ever been knocked unconscious? If yes, for how long and under what circumstances?
9. Have you ever been in a car accident? If yes, did you get whiplash? (describe)
10. Have you ever had an epileptic fit? If yes, describe.
11. Have you ever suffered febrile seizures (high temperature induced fits or seizures), especially between 8 months and 3 years? If yes, describe.
12. Do you suffer from asthma? Taking medication for it? Which and how often?
13. When did you start to crawl? Did you crawl normally - opposite hand and knee - or did you tend to scoot along on your bum or drag/extend one leg?
14. When did you start talking? Was there any verbal language delay? If so, how long?
15. Any household pets or other animals you or your family members are in close contact with?
16. How would you describe your mood on a day-to-day basis?
17. Any other facts or information that you feel are relevant?
Most recent physical examination:
Purpose:
Other:
Current medical treatment, impending surgery, genetic/development delay, or other treatment?
List all drugs you are currently taking and their purpose:
Explain:
Explain:
Explain:
Explain:
