Intake Forms Page 1

The Kids' Communication Center, LLC

4906 Wisconsin Ave., NW

Washington DC 20016

202-486-7388

laura@thekidscommunicationcenter.com

Please complete this form to the best of your ability. All fields require a response before submitting, but you may enter "unknown" if unsure or "N/A" if not applicable to your child.

Child's First Name

Child's Middle Name

Child's Last Name

Date of Birth

Sex

Responsible Party

Today's Date

Relationship to Child

Cell Phone

Home Phone

Work Phone

Address

E-mail

Name of Caregiver/Nanny

Phone & E-mail of Caregiver/Nanny

Does your child have any siblings?

If yes, what are their ages?

Pediatrician

Pediatrician's Address

Has your child ever been given a medical diagnosis?

If yes, what diagnosis?

What was the treatment?

Were there any complications (e.g., maternal health problems, bed-rest, medications) with the pregnancy? Explain.

How long was the mother on bed-rest?

Was the child born premature?

Please provide details as to difficulties and treatment.

Were there any complications during labor and/or delivery (e.g., forceps, vacuum extraction)? Explain.

Apgar Scores

Child's Birth Weight

Was your child admitted to the NICU?

If so, explain (include length of stay).

Was your child nursed?

If so, until what age?

Was there anything remarkable about your child’s early feeding history?

Has your child ever suffered from ear infections?

If yes, how many?

Which ears?

At what age(s)?

Were PE tubes inserted?

If yes, at what age?

Does your child have fluid in his/her ears?

If yes, for how long?

Has your child’s hearing been tested?

When?

Where?

What were the results?

Is your child sensitive to certain sounds/pitches (e.g., vacuum cleaners, blenders)?

Does your child cover his/her ears when he/she hears certain sounds? (specify)

Does your child seem under-reactive to loud sounds (e.g., ambulance)?

Is your child on any medications? (specify)

Does your child have any allergies? (specify)

Did your child ever suffer from reflux?

Were any medications prescribed?

Explain your child’s typical eating habits.

Does your child crave food?

If yes, please list.

Does your child have any food allergies?

Yes

Never tested

If yes, describe.

When eating, does your child prefer specific textures (e.g., mushy, crunchy), tastes (e.g., sour, sweet, bland) or temperatures (e.g., hot, cold)?

What is the texture of the child’s stools? (liquid/formed/paste)

Please provide examples of regularly consumed foods that are:

Mushy

Crunchy

Chewy

Sour

Sweet

Bland

Cold

Hot

Please describe a typical breakfast.

Please describe a typical lunch.

Please describe a typical dinner.

Please describe typical snacks.