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ML™ Intake Form (Child)

This is an intake form for new clients

 

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Question 1 of 27

Date and Time of Appointment. (If intensive, please write all dates and times)

Question 2 of 27

Parent's Name:

Question 3 of 27

Patient's Name: 

Question 4 of 27

Patient's date of birth:

Question 5 of 27

E-mail: 

Question 6 of 27

Address and Timezone

Question 7 of 27

Phone Number:

Question 8 of 27

What service will you get with Movement Lesson™?

A

1-hour In-Office Consultation (child)

B

Child Intensive. (10 sessions a week)

C

1-Hour ONLINE Consultation

Question 9 of 27

Is this your first time in Movement Lesson™?

A

Yes

B

No

Question 10 of 27

How did you hear about Movement Lesson™?

A

Friend

B

Facebook

C

YouTube

D

Google

E

Other

Question 11 of 27

What is the diagnosis?

Question 12 of 27

Please list past hospitalizations, surgeries, accidents, and major illnesses (include dates):

Question 13 of 27

Please list all medication use (Prescription and over the counter). 
Medication, Dose, Frequency, Date Started

Question 14 of 27

Are there any siblings in the household?

A

No

B

Yes, 1

C

Yes, 2+

Question 15 of 27

When was the last Gastroenterologist visit? (List complications if any)

Question 16 of 27

When was the last eye doctor visit? What kind of Specialist? Any concerns?

Question 17 of 27

What type of delivery was your child delivered in?

A

Vaginally without Medication

B

Vaginally with Medication

C

Vacuum Extraction

D

C-Section

E

Other

Question 18 of 27

Did your child stay in the NICU?

A

No

B

Yes, less than 5 days

C

Yes, 6-14 days

D

Yes, 2-4 weeks

E

Yes, more than 1 month

Question 19 of 27

Does your child have a Gastrostomy tube (G-tube), Nasogastric tube (NG-tube) or Nasojejunal tube (NG/J-tube)?

A

G-tube

B

NG-tube

C

NG/J-tube

D

No

Question 20 of 27

Does your child have seizures?

A

Yes

B

No

Question 21 of 27

Is your child Light Sensitive to certain objects?

A

Yes

B

No

Question 22 of 27

Is your child Sound Sensitive to certain sounds? 
(Ex: Car, Vacuum)

A

Yes

B

No

Question 23 of 27

Does your child prefer a certain position?

A

Laying on their back

B

Laying on their back, head slightly raised

C

Laying on their side (Left side only)

D

Laying on their side (Right side only)

E

Laying on their tummy

F

Sitting up only

G

Any position is fine

Question 24 of 27

Does your child prefer to look one way over the other?

A

Mainly to the Left

B

Mainly to the Right

C

Only Straight ahead

D

Looks both ways equally

E

Not sure

Question 25 of 27

Does your child roll-over from belly to his/her back, unassisted?

A

Yes

B

No

Question 26 of 27

Does your child transition from sitting to his/her back?

A

Yes

B

No

Question 27 of 27

Please select all milestones that your child has accomplished: 

(Select all that apply)
A

Rolling over from back to belly

B

Rolling over from belly to back

C

Sitting up

D

Reaching with one side

E

Reaching with both sides

F

Crawling

G

Standing

H

Walking with some assistance

I

Walking with no assistance

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