Potential, Performance & Possibility Group Healing Sessions -- Health History and Initial Symptom Form for Session #1 on September 8, 2020
Please fill out these questions and submit by September 5, 2020.
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Name of person/parent or caregiver who will attend the Group Healing Sessions for the child: *
Today's Date: *
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Child's full name: *
Child's date of birth: *
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Child's age, as of today: *
Email address (for appointment reminders and other communication from Autism Transformed team members) - please double check for accuracy before submitting: *
Phone number (the best one to reach you at), please include area code or country code if applicable (Indicate if this number accepts texts also.) *
Biggest challenges for your child - please list them all and rank them numerically with 10 being the the biggest challenge (for example:  1. Low expressive speech - 9/10, 2. Aggressive at school - 4/10, 3. Stimming and hand flapping - 5/10, 4. Limited in what they will eat - 8/10, 5. Constipation - 8/10, 6. Sleep issues - 9/10, etc.).
OVERALL HEALTH: Check off the symptoms for your child.
OVERALL HEALTH QUESTION: If you checked developmentally delayed above, please list below where you see the developmental delay (i.e. reading - age 6, gross motor skills - age 3, social skills - age 2, fine motor skills - age 3).
SUSPECTED PANS/PANDAS(check what applies):
PANS/PANDAs: severity (1-10 scale) and other comments
SUSPECTED EXPOSURE TO MOLD (check what applies):
MOLD: severity (1-10 scale) and other comments
SUSPECTED EXPOSURE TO LYME (check what applies):
LYME: severity (1-10 scale) and other comments
ANTIBIOTICS: How many times has your child had antibiotics?
VACCINES: Has your child had vaccines, reaction to vaccines; describe their vaccine experiences.
ENERGY LEVEL: In your own words, describe your child’s energy level (for example: wired but tired, lethargic and listless, seems hyper, always moving, low muscle tone).
ENERGY LEVEL: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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FOOD/DIET: In your own words, describe your child's food/diet (name special diet and cheats, supplements, picky eater, allergies, sensitivities, poor appetite, hungry a lot).
FOOD/DIET: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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DIGESTION: In your own words, describe your child’s digestive situation (pushes belly on things, sensory seeking in this way, bloated, passes lots of gas, doesn’t digest food well/undigested food in poop, abdomen is hard and feces seems compacted, diarrhea, etc).
DIGESTION: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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POOP: In your own words, describe your child’s poop in detail (for example: great, well formed bowel movement every day, or 2-3x/day, poops every 3 days, poop is mushy, diarrhea, diarrhea alternates with constipation, poop is hard, like little rabbit pellets, he/she has a hard time getting it out, is afraid of going on the toilet, is extremely smelly, tarry or other description).
POOP: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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URINE: In your own words, describe your child’s urinary habits (not toilet trained for age, overly smelly urine, frequent urination, urine is cloudy, wets the bed, thirsty a lot, drinks a lot of water by his/her choice).
URINE: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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SLEEP: In your own words, describe your child’s sleep (do they sleep not enough, too much for their age, just the right amount, difficulty falling asleep, staying asleep, wakes too early, up for hours in the night, etc).
SLEEP: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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SKIN: In your own words, describe your child’s skin (psoriasis, eczema or rashes, now or in history).
SKIN: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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RESPIRATORY ISSUE: In your own words, describe your child’s respiratory issues (asthma, breathing issues, chronic infections in lungs, sinuses, mouth breather, snores, sleep apnea).
RESPIRATORY ISSUES: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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MUSCLE/JOINT: In your own words, describe your child’s muscular and joint issues (pain anywhere, weakness, swelling, spinal issues, numbness, cramping; describe issue and where it’s happening).
MUSCLE/JOINT: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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EARS/HEARING: In your own words, describe your child’s ears/hearing, auditory abilities (known issues with ears, hearing, lots of ear infections and antibiotics, balance is off, auditory processing delay, etc).
EARS/HEARING: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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VISION: In your own words, describe your child’s vision (writing, reading, number, letters, eye coordination, etc).
VISION: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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ALLERGIES: In your own words, describe your child’s allergies. Any known allergies to inhalents (dust, mold, pollen, etc), ingestants (foods, other things that go in the mouth), injectants (bug bites, stings, man made injections), contactants (anything that touches the skin).
ALLERGIES: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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SENSORY: In your own words, describe your child’s sensory situation ([over or under] to touch, sound, smell, light, EMF/cell phones/wifi, weather, food textures, pain response).
SENSORY: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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MOTOR SKILLS: In your own words, describe your child’s motor skills (gross, fine, include info about writing, tying shoes, walking, jumping, hopping, level of physicalness or athleticism, ability to cross midline of body, toe walking, apraxia, mouth-chewing, speech, breastfeeding [able to latch on?]).
MOTOR SKILLS: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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COMMUNICATION/SPEECH: In your own words, describe your child’s communication and any speech issues (non-verbal or low verbal, repetitive speech, non-expressive, can only say 3 word sentence, etc.).
COMMUNICATION/SPEECH: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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COGNITIVE ISSUES: In your own words, describe your child’s cognitive issues (not answering questions appropriately, doesn’t seem to understand directions, understands directions with 1, 2, 3, 4, steps [i.e. pick up the paper, put it in the trash, pick up your ball, then throw it, then come here), difficulty remembering, seeming disoriented or lost, cannot follow the subject being discussed/taught).
COGNITIVE ISSUES: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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ANXIETY: In your own words, describe your child’s anxiety and how it shows up (for example: not wanting to vary from a rigid routine, carrying something around as security, clinging to a parent or caregiver, unable to look in the eyes of others outside the family, shies away from people, events, places, other).
ANXIETY: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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ATTENTION/ATTENDING/FOCUS: In your own words, describe your child’s ability to attend or focus on a task (is it less than a few seconds, hyper focused, unable to sit still to attend, etc.)
ATTENTION/FOCUS: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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TANTRUMS OR OTHER UNDESIRABLE BEHAVIOR: In your own words, describe your child’s tantrums or other undesirable or inappropriate behavior.
TANTRUMS OR OTHER UNDESIRABLE BEHAVIOR: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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OBSESSIONS: In your own words, describe your child’s obsessions with objects, action, person, etc.
OBSESSIONS: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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SOCIAL: In your own words, describe your child’s social status (doesn’t have friends who understand him, gets lost following play with others, isolates from others, interacts better with adults than children, is aggressive or doesn’t understand how to be towards others, other).
SOCIAL: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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EMF SENSITIVITY: In your own words, describe your child's sensitivity to EMF’s (seems sensitive to cell phone, wifi, around cell towers, light, radio waves, etc, other wave forms).
EMF SENSITIVITY: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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OTHER BEHAVIORS: In your own words, describe any other behaviors (such as  toe walking, flapping, rocking, head banging, pink cheeks and ears – especially after eating, behavior changes after eating, amped up behaviors at the full or new moon, or other things).
OTHER BEHAVIORS: How severe of an issue is this (1-10 scale) THIS WEEK? Write the number below.
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Which supplements does your child currently take (i.e. zinc, multi vitamin, probiotics, liver herbs, adrenal herbs, fish oil, magnesium, etc.) Please include item name and dosage. Please hit enter after each one listed so they each go on a separate line.
Gluten-Free diet
Casein-Free diet
Other-free diet (please list, i.e. soy, corn, egg, etc)
Other special diet (SCD, keto, paleo, GAPS, etc)
Biomedical treatment (supplement regime from a DAN or MAPS autism doc or other practitioner. If anything different from listed supplements above.)
Homeopathy (name/type of homeopathy, i.e. traditional/constitutional, sequential, homotoxicology, for vaccines, etc.)
Auditory therapies, like Tomatis or others
Speech therapy
Reflex Integration (name method)
Neuro Modalities (i.e. Neurofeedback, name therapy)
Allergy Treatment (like NAET, name therapy)
Detox Footbath or other Detox strategies (name them)
Accupuncture/pressure
Cranial Sacral Therapy
Chiropractic
Occupational Therapy
Applied Behavioral Analysis (ABA)
Vision Therapy
Chewing/eating therapy
My child is diagnosed with (fill in the diagnosis)
If diagnosis is Autism, it is regressive autism?
If diagnosis is Autism, it is NOT regressive autism
Mom had silver (amalgam) fillings previous to or during pregnancy
Mom has allergy or autoimmunity (please say which)
Mom has digestive issues (please describe)
Is your child vaccinated - indicate which ones - some or all, full course, etc.?
Are there any other things you want to mention?
You've reached the end of the form. Thank you for taking the time to be thorough, as it will help inform the NMT session!
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