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Registration

Chief Complaints

Birth History

Was the baby born at full term?
Yes
No
Unknown
How was the baby delivered?
Vaginal Delivery
Caesarean Section/C-section
Did the mother use any tobacco, alcohol, drugs, or medications during pregnancy?
Yes
No
Were there any complications during pregnancy, during birth, or after birth?
Yes
No
Was a NICU (Neonatal Intensive Care Unit) stay required?
Yes
No
Did the baby go home with the mother from the hospital?
Yes
No

Medical History/Review of Systems

Does your child have, or has your child ever had:

Does your child have, or has your child ever had:

Surgical History

Have any biological family member had the following?

From what city and country are the child’s biological:

Are the biological mother and father related/from the same family?
Yes
No

Social History

Which of these best describes the child’s living situation?
Lives with both biological parents
Lives with one biological parent (but joint custody)
Lives with foster family
Lives with adoptive parents
Lives with one biological parent (sole custody)
Other

Please list most recent grades or performance in the following subjects:

Did the child ever repeat a grade at school?
Yes
No
Did the child ever have a Child Study Team evaluation?
Yes
No

IMPORTANT:

If your child has ever had a Child Study Team (CST) evaluation and/or Individualized Education Program (IEP), be sure to bring an updated copy to the examination

Is your child receiving special accommodations at school?
Yes
No

Developmental History

Has your child every regressed (that is, lost or forgot developmental skills)?
Yes
No

Around how old was your child when he/she was consistently able to do the following? (Say "Unable to do this" if your child cannot do this action)

Has your child ever received developmental therapies?
Yes
No
If YES, which therapies?

Medications

Allergies

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