Past Evaluations

Please indicate if you have had any of the following evaluations, treatment, or consultations by placing a check mark in the appropriate columns. Please attach any copies of reports or provide the addresses where the evaluations took place. Add comments (to the back or attach sheet if needed).

Evaluation / Test

Hospitalizations

Mother’s History:

Developmental History

Please indicate the approximate age in months for the following milestones

Immunization

Please give approx. date if you do not have the exact one.

Did you have any of the following reactions: “Bowel” means any bowel symptom such as diarrhea, “Swelling” means swelling at the site of injection.

Environmental History

Please indicate past and present exposures

VESTIBULAR FUNCTION CHECKLIST

The vestibular system is all about balance and spatial awareness. These are signs of a problem in this area. Read each of the following symptoms and place a check in the box that most closely fines how it describes your child. Number 1 indicates “doesn’t apply at all” and a 10 is “almost always”. Add up the numbers and record the total. (The lowest possible score is a 10 and the highest is 100).

AUDITORY FUNCTION Checklist

These are the symptom of a problem with the auditory sensory system. Read each of the following symptoms and place a check in the box that most closely fines how it describes your child. Number 1 indicates “doesn’t apply at all” and a 10 is “almost always”. Add up the numbers and record the total. (The lowest possible score is a 10 and the highest is 100).

VISUAL DYSFUNCTION CHECKLIST

This checklist focuses on symptoms that make reading difficult. If you are unsure, talk to your child’s teacher or do some reading exercises with your child. Read each of the following symptoms and place a check in the box that most closely defines how it describes your child. 1 indicates “doesn’t apply at all” and a 10 is “almost always”. Add up the numbers and record the total. (The lowest possible score is a 10 and the highest is 100).

PROPRIOCEPTIVE FUNCTION CHECKLIST

This checklist will help judge how well your child feels his or her body in space. Read each of the following symptoms and place a check in the box that most closely fines how it describes your child. Number 1 indicates “doesn’t apply at all” and a 10 is “almost always”. Add up the numbers and record the total. (The lowest possible score is a 10 and the highest is 100).

TACTILE FUNCTION CHECKLIST

These symptoms indicated either and under of over sensitivity to touch. Read each of the following symptoms and place a check in the box that most closely fines how it describes your child. A 1 indicates “doesn’t apply at all” and a 10 is “almost always”. Add up the numbers and record the total. (The lowest possible score is a 10 and the highest is 100).

HYPOTACTILE (oversensitivity) Symptoms

HYPERTACTILE (Undersensitivity) Symptoms

OLFACTORY FUNCTION CHECKLIST

These two checklists will help you ascertain if your child has deficiency in the senses of smell and taste. One list checks for oversensitivity and the other under-sensitivity. Read each of the symptoms in both lists and place a check in the box that most closely defines how it describes your child. A 1 indicates “doesn’t apply at all” and a 10 is “almost always”. Add up the numbers and record the total. (The lowest possible score is a 10 and the highest is 100). Total each list.

Hypersensitive Smell and Taste Checklist

Hyposenitive Smell

Child Neurotransmitter form

Medication History

Please circle any of the following medications your child has or are currently taking.