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Intake Form for:

Autistic Spectrum Disorder, ADHD, and
Related Neurodevelopmental Disorders for Children

Directions:

Please open your browser window to the largest possible size.
Use the tab key or your mouse to move from one field to the next. If you hit the "Return" key, the form will be submitted.
Answer all questions to the best of your ability.
Before submitting the form, please print a copy for your records.

Which doctor would you like to schedule with:

Email:

Child's Legal Name:

Preferred Name:

Parents' Names:

Address:

City:

State:

Zip:

Home Phone:

Daytime Phone:

Cellular Phone:

Child's Birth Date:

Parents Ages:

What neurobehavioral diagnosis has your child been given?
Autism PDD nos ADHD/ADD OCD developmental language disorder	developmental coordination disorder No formal diagnosis Other (Please Specify)

Who gave you the diagnosis?

Regional center
developmental psychologist
Neurologist
Pediatrician
Psychiatrist

therapist
Other (Please Specify)

Date or age you suspected delayed development:

Did you feel that delay was related to vaccine? Yes No Not sure

List the family members and others who live with you including pets.

Pregnancy Information

How many (if any) Silver Amalgam (Mercury) fillings did the mother have in her mouth during gestation?
None 1-4 4-8 more than 8

Describe any dental procedures done during pregnancy or breast feeding:

Describe fish consumption during preganancy and breast feeding:

Breast Feeding Period
less than 1 month
1-6 month(s)
6-18 months
18 months - 3 years
more than 3 yrs

still breastfeeding

Colic or Milk Intolerance? YES NO
Describe symptoms:

We are currently doing the following dietary intervention:

GFCF(gluten-free casein free)
SCD
Feingold
Diet based upon Allergy Testing
Soy Free

Corn Free
Sugar Free
Other (Please Specify)

If not, have you tried any specific diets in the past? If so, please describe

Does your child have sensory issues?
light sensitivity
sound sensitivity
tactile sensitivity (devensive)
Seeks deep pressure
oral issues (textures)

Describe the therapies your child has received and how they did.
ABA	hours per week positive negative neutral
RDI	hours per week positive negative neutral
Occupation therapy	hours per week positive negative neutral
Speech Therapy	hours per week positive negative neutral
Therapeutic Listening	hours per week positive negative neutral
Tomatis	hours per week positive negative neutral
Sensory Integration Therapy	hours per week positive negative neutral

Is your child potty trained? urine stool

List all medications
(one medication per line e.g Zantac 75mg twice daily, Nystatin 500k units three times daily)

List all supplements
(one supplement per line – eg Vitamin C 250mg twice daily, Cod Liver oil 1 tsp daily)

List all medical problems
(one problem per line - eg Eczema, Diarrhea, Reflux)

What are your goals for your child's medical care?
(in order of importance)

What else would you like for us to know about your child or your family?

BEFORE YOU SUBMIT THIS FORM, Please make sure your browser screen is open to the largest possible size and then print a copy for your records.

By clicking submit, I acknowledge that there is a 24 hour cancellation policy, and I will be responsible for the Doctor's fees for any no-shows or cancellations after 24 hours if the appointment slot can not be filled. I further authorize Vitality Health & Wellness to charge my credit card for any appointments that I fail to come to without 24 hours notice during business hours (i.e. a cancellation for a 4pm appt on Monday must be cancelled by 4pm on the previous Friday)..

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