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Pediatric Intake Form
Pediatric Intake
Parent's First Name:
Parent's Last Name:
Child's First Name:
Child's Last Name:
Child's Date of Birth
Address:
Phone:
Email:
Emergency Contact: Name and Phone Number
Gestation/Pregnancy - Length of Pregnancy (# of weeks)
Labor/Delivery History Birth History
Biological Child
Adopted
Foster
Was your child delivered at
Home
Birth Center
Hospital
What type of delivery did your child have?
Vaginal
C-section
In what position did your child present? (Cephalic, Breech, etc.)
How long was the labor?
How much time was spent pushing?
Was Epidural or Pitocin administered?
Were forceps or vacuum suction used to assist in delivery?
Did the midwife or physician need to pull or twist your child to assist in delivery?
Was the umbilical cord wrapped or knotted before or during birth? (if yes, please explain.)
Did your child need assistance breathing after delivery?
Did your child spend any time in the NICU? (If yes, please explain.)
Was your child assessed and/or diagnosed with any oral ties? If yes, did your child receive a revision and when?
Weight and length of your child at delivery.
Please share any other information that you would like us to know about your child’s birth.
Health and Wellness History Does or did your child breastfeed, bottle feed, or both?
Breastfeed
Bottle fed
Both
Were or are there any feeding issues?
Does or did your child spit up or vomit?
Yes
No
Does or did your child have colic?
Yes
No
Does or did your child have chronic gas?
Yes
No
Does your child have constipation or have a history of constipation?
Yes
No
Does or did your child arch his/her back, throw his/her head back, or make himself/herself stiff? If yes, please explain.
Does or did your child have difficulty sleeping? If yes, please explain.
Please list all your child’s surgeries and any medical procedures (spinal tap, IVs, etc.). Include the approximate dates of procedures.
Please list any traumas that occurred to your child since delivery (falls, accidents, emotional trauma, etc.). Include the approximate dates of the injury.
Please list any traumas that occurred to your child since delivery (falls, accidents, emotional trauma, etc.). Include the approximate dates of the injury.
Please list your goals for your child's FMCM or Matrix in Motion Somatic Therapy program.
Is your child under the care of a primary healthcare provider or specialist?
Yes
No
Name of healthcare provider and/or facility.
My child is developing like an average child for his/her age in all areas of development.
Yes
No
My child is developing differently than an average child for his/her age in any area of development.
Yes
No
If yes, please describe
Please list any medications or supplements your child is now taking.
Please list any special dietary/nutritional considerations for your child (Ex. Gluten free, allergies)
Dental History (if applicable) Has your child had any teeth extracted? If so, how many?
Does your child currently wear orthodontic appliances or has he/she worn them in the past?
Therapeutic History Has your child ever received massage, bodywork, or manual therapy (professionally or by parent’s touch)? (Ex. Chiropractic, MNRI, Craniosacral, other energy modalities) If yes, please list.
If yes, how did your child respond to the therapy?
Please list any complimentary therapies or educational programs in which your child participates:
How does your child respond to touch or movement? Does your child – Dislike being held or cuddled?
Never
Some
Often
Always
In the past
This is a problem
Seem irritated when touched?
Never
Some
Often
Always
In the past
This is a probelm
Bang or hit head on purpose?
Never
Some
Often
Always
In the past
This is a problem
Seems overly aware of touch, texture, and temperature?
Never
Some
Often
Always
In the past
This is a problem
Has an increased response to pain?
Never
Some
Often
Always
In the past
This is a problem
Lack awareness of being touched?
Never
Some
Often
Always
In the past
This is a problem
Bite, chew, or suck on a blanket, pacifier, or other objects to calm?
Never
Some
Often
Always
In the past
This is a problem
Frequently bump into or push people or items?
Never
Some
Often
Always
In the past
This is a problem
Has a strong need to touch objects or people?
Never
Some
Often
Always
In the past
This is a problem
Try to bite people?
Never
Some
Often
Always
In the past
This is a problem
Dislikes car seat?
Never
Some
Often
Always
In the past
This is a problem
Seeks out rough housing play?
Never
Some
Often
Always
In the past
This is a problem
Has a fear in space (heights, on stairs, etc.)?
Never
Some
Often
Always
In the past
This is a problem
Authorization and Disclaimer Information I understand that my child will be participating in Matrix Energy Healing/FMCM as a form of adjunct healthcare. I have noted in my intake all complications, risks, or conditions my child has experienced, and I have obtained my child’s healthcare provider’s release if necessary. I understand that my child will receive Matrix Energy Healing as a form of adjunctive health care only and that it is not a substitute for other health care provided by a medical doctor. I hear by release and hold harmless and defend the Myers Institute®/FMCM Specialist from any claims, liability, demands, and causes of action from my and my child’s participation in therapy.
Name:
Date
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®
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484.336.3243
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