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™?
1-hour In-Office Consultation (child)
Child Intensive. (10 sessions a week)
1-Hour ONLINE Consultation
Question 9 of 27
Is this your first time in Movement Lesson™?
Yes
No
Question 10 of 27
How did you hear about Movement Lesson™?
Friend
Facebook
YouTube
Google
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?
Yes, 1
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?
Vaginally without Medication
Vaginally with Medication
Vacuum Extraction
C-Section
Question 18 of 27
Did your child stay in the NICU?
Yes, less than 5 days
Yes, 6-14 days
Yes, 2-4 weeks
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)?
G-tube
NG-tube
NG/J-tube
Question 20 of 27
Does your child have seizures?
Question 21 of 27
Is your child Light Sensitive to certain objects?
Question 22 of 27
Is your child Sound Sensitive to certain sounds? (Ex: Car, Vacuum)
Question 23 of 27
Does your child prefer a certain position?
Laying on their back
Laying on their back, head slightly raised
Laying on their side (Left side only)
Laying on their side (Right side only)
Laying on their tummy
Sitting up only
Any position is fine
Question 24 of 27
Does your child prefer to look one way over the other?
Mainly to the Left
Mainly to the Right
Only Straight ahead
Looks both ways equally
Not sure
Question 25 of 27
Does your child roll-over from belly to his/her back, unassisted?
Question 26 of 27
Does your child transition from sitting to his/her back?
Question 27 of 27
Please select all milestones that your child has accomplished:
Rolling over from back to belly
Rolling over from belly to back
Sitting up
Reaching with one side
Reaching with both sides
Crawling
Standing
Walking with some assistance
Walking with no assistance