New Patient Intake Form | Blair Complex-Care

Intake Form

Please fill out completely

First Name

Last Name

Parent(s) First and Last Name

Type and Select Address

Phone

All appointments will be via phone call. If you live within the US, I will call the listed number above directly. If you are international, and would prefer a phone call via WhatsAPP or Facebook. Please list below.

Choose your child's Gender

Male

Female

Birthday

Child's Weight (lbs)

Were you referred to me by another parent, if so, who?

Mother's health (please list any past or current health issues)

Father's health (please list any past or current health issues)

List any medications or vaccinations mother received during pregnancy:

List any complications during pregnancy:

Gestational age at delivery (how many weeks of pregnancy):

Childbirth: vaginal or cesarean?

List any complications during or after delivery:

Was your child breast fed?

Yes

If yes, for how long?

If your child was formula fed, what formula was used?

Was your child fully vaccinated according to CDC schedule?

Yes

Did your child display any obvious or adverse reactions following any vaccinations? Please explain

How was your child's first year of life, did they meet developmental milestones appropriately?

Has your child received any antibiotics, required a hospital stay, or had any procedures performed? Please list each, including medications and anesthesias used.

Did your child ever experience a regression? If so, when, and what skills were lost?

When did you start to have concerns about your child's development? What actions did you take?

Where have you resided since pregnancy? List all locations, and approximate year each home was built. Do you have any concerns of exposure to mold?

What traditional therapies has your child participated in and were they helpful?

What alternative or biomedical interventions have you tried?

If you have implemented any biomedical interventions or supplements, were there any you found to be particularly beneficial? Please explain.

If you have implemented any biomedical interventions or supplements, were there any that your child did poorly with or did not tolerate? Please explain.

Have you worked with any functional medicine or MAPS doctors, homeopaths, nutritionists, etc? If so, please list.

Have you had any diagnostics or lab work performed? Please list each, including year completed. Please email all previous labs after submitting this intake form to: P.Brooks@TheBlairInstitute.com

How is your child's sleep?

How are your child's digestion and bowel habits? Please list frequency and texture of bowel movements.

How is your child's diet, are they currently on any restrictive diets or trialed any in the past? Are they a picky eater? Please list what foods they primarily eat.

How is your child's social interaction and engagement? Are they affectionate?

How is your child's expressive language, speech, and communication? Please explain.

How is your child's receptive language, cognition, and understanding? Are they able to follow single or multi-step directions?

How are your child's motor skills? Please describe fine and gross motor capabilities or challenges.

Is your child in school? If so, what grade? Are they receiving any accommodations or do they have an IEP? How are they doing in school? Please explain.

What are your child's biggest strengths?

What are your child's biggest challenges?

What are your goals; what would you like to gain by working with me?

Are there any challenges that could prevent you from being successful in implementing treatment? (financial, logistical, etc)

Is there any additional information you would like me to know that would be helpful for me in understanding your child?

Do you have any specific treatments or protocols in mind that you would like guidance with?

What is your child's school/therapy schedule?

I agree to read and sign the following forms: Parental Agreement and Waiver

Thanks for submitting!