Phone:
Phone/Fax:
Print Preview Print Clear
INTAKE FORM – CHILD
Today's Date (MM/DD/YYYY):
Form Is Completed by Self Parent: Guardian:
Name of Client Date of Birth: Age:
Address:
Phone/Fax:
Parent(s) or Guardian(s) of a Minor:
Physician/Other Health Professional (chiropractor, therapist, naturopath, bodyworker, etc.):
Referral Source (if referred to this office): Phone: (H)
Diagnosis: Current Medication:
Medical history
Client’s Birth Weight: lbs  oz
Length of Pregnancy:  Adopted at Age:
Complications during Pregnancy and or Delivery
Yes/NoDetails
Prenatal Stress or Injury
Prenatal Drug/Alcohol Exposure
Growth and Development
Typical/More/LessDetails
Activity Level
Motor/Coordination Development
Infections/Allergies
Emotional Development
Behavioral Concerns
Handedness Development
Appetite/Digestion
Language/Speech Development
Physical Traumas
Yes/NoDetails
Head Injuries (even manor falls, etc.)
Coma (loss of consciousness)
Accidents (list all)
Height Fever
Serious Illness
Surgery
CNS Infection
Drug Overdose/Poisoning
Recreational Drug Use
Anoxia
Stroke
Psychological Stress/Life Changes
Yes/NoDetails
Death in Family
Divorce/Remarriage
Move/Relocation
School Change
Job Change
Family Member Chronic Illness
Health/Diet
Was the Client Nursed? (Yes/No):  If Yes, Until What Age?:
Describe the Client’s Diet:
Excessive/Daily/Weekly/Rarely/Never
Vegetables
Fruits
Meats
Sugar
Artificial Sweeteners
Artificial Colorings
Dairy Products
White Flour
Tobacco
Alcohol
List Dietary Supplements and Vitamins:
Behavior
Does the Client Have a History of Emotional or Behavioral Disorders? (Yes/No):
Describe:
If There a Family History of Emotional or Behavioral Disorders? (Yes/No):
Describe:
Client’s Specific Positive Behaviors:
Client’s Specific Negative Behaviors:
Do you Have Specific Behavioral Goals for the Client? (Yes/No):
Describe:
Yes/No/Not Sure
Distractibility
Short Attention Span
Hyperactive
Hypoactive (low activity level)
Rigid or Inflexible
Impulsive
Temper Tantrums
Sucks Thumb
Few or No Friends
Socially Immature
Perseverating
Low Frustration Level
Overreacts
Destructive Behavior
Aggressive Behavior
Cyclical Behavior
(good days/bad days)
Academic Output
(good days/bad days)
Achievement (high in
some cases, but low others)
Disorganized
Yes/No/Not Sure
Avoidance Behavior
Likes Competitive Games
Overly Sensitive
Difficulty Following Directions
Difficulty With Parents
Difficulty with Siblings
Difficulty With Teachers
Difficulty with Peers
Overly Sensitive to Sound
Overly Sensitive to Touch
Overly Sensitive to Odors
Tics
Phobias
Emotional
High Tolerance for Pain
Low Tolerance for Pain
 
Compliant Cooperative
 
Obedient
 
Organized
Flexible Social
Educational History
List All Schools/Programs Attended, Grade Completed and/or Degree Earned:
List Any Educational Problems (Past or Current):
List Any Labels, Classifications, or Educational Diagnoses (Past or Current):