Name *

First Name

Last Name

Birth date

MM

DD

YYYY

Phone *

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General health:

Difficulty falling asleep or staying asleep

Difficulty waking

Restless sleep

Sleepwalking or night terrors

Nightmares

Teeth grinding

Allergies

Asthma

Fatigue

Is always hungry

Suddenly becomes shaky without food

Unusual eating habits

Sense of taste

Thirst awareness

Heat or cold sensitivity

Thyroid disorder

Sense of smell

Skin problems

Low pain threshold

High pain tolerance

Earaches

Bruxism (teeth grinding)

Visual acuity:

Blurred vision

Eye pain

Sensitivity to light

Hearing:

Hearing loss

Ringing in ears

Sensitivity to sound

Cardiovascular / pulmonary:

Breathing problems

Heart problems

Hypertension

Palpitations or tachycardia

Gastrointestinal:

Nausea or vomiting

Stomach pain

Intestinal pain

Chronic constipation

Irritable bowel

Crohn's disease

Pain:

Chronic pain or stiffness

Chronic aching pain

Chronic nerve pain (burning or stabbing)

Muscle cramps

Headaches

Neurological:

Migraines

Fainting

Seizures

Speech problems

Tremor or spasticity

Weakness

Balance

Coordination

Accident prone

Motor or vocal tics

Attention and cognitive:

Difficulty reading

Difficulty with reading comprehension

Difficulty with math

Learning disability

Developmentally delayed

Dyslexia

Poor sense of direction

Difficulty concentrating

Impulsive

Artistic

Hyperactive

Urogenital system:

Bedwetting

Wets pants

Behavior / emotions:

Depressed

Anxious

Panic attacks

Difficulty managing emotions

Angry outbursts

Tantrums

Defiant

Mood swings

Fears of the dark or other extreme fears

Very routine in behaviors

Unable to sit still

Excessive worry

Fearless

Lack of facial expressions

Repetitive speech

Obsessive about interests

Unusual reactions to way things sound, smell, taste, look or feel

Short attention span

Fidgety / restless

Difficulty completing tasks

Easily distracted

Forgetful

Poor time management

Trouble multi-tasking

Early childhood development:

Prenatal stress or injury

Prenatal drug exposure

Difficult labor

Difficult birth

Premature or late birth

Medical problems after birth

Adopted

Sleep problems

Eating problems

Attachment difficulties

Emotional development

Delayed movement and motor skills

Delayed language development

Delayed cognitive or learning skills

Chronic ear infections

Allergies

Asthma

Avoids eye contact

Does not respond to name

Not smiling when others smile at him/her

Repetitive movements, such as rocking, spinning or hand flapping

Social skills:

Social anxiety

Difficulty making friends

Lack of empathy

Lack of ability to express feelings

Repetitive daily routines

Takes things very literally

Limited interests

Physical traumas:

Head injury

Concussions

Accidents

Serious illness

CNS infection

Drug overdose

Poisoning

Anoxia

Stroke

Sports:

Football

Soccer

Boxing

Martial arts

Dance

Baseball

Weight lifting

Track / long distance running

Other

History of trauma & stress:

Parental divorce

Family stress

Verbal or emotional abuse

Physical abuse

Sexual abuse

Absent father

Absent mother

School stress

Recent death in family

Illness

Family history:

Check all that apply and note relationship of family member.

Alcoholism or drug abuse

Asthma

Autoimmune disorders: I Diabetes, Rheumatoid Arthritis Lupus, MS, Scleroderma, etc.

Thyroid disorder

Migraine

Sleep problems

Depression

Sleep problems

Phobias

Manic-depression

Panic attacks

Motor or vocal tics

Seizures

Eating disorders or obesity

Addictions

Obsessive compulsive symptoms

Speech problems

Hyperactivity

Learning problems

Conduct problems or criminal behavior

Autism spectrum

Schizophrenia

Diabetes

Anxiety