Phone Consultation Questionnaire

Your Name:

First NameLast Name

Date

MonthDayYear

Where did you hear about us?

In what country do you live?

If USA, what state do you live in?

What time zone are you in?

Best contact E-mail

What phone number is best to contact you?

Format: (000) 000-0000.

Best time to talk (select multiple)

Name of individual with whom you are concerned:

First NameLast Name

Individual's age:

Has the individual been given any learning labels?

If yes, please include labels below:

Hand Dominance

Please indicate the level of concern for the individual in the following areas:

Rows	No Concern	Mild Concern	Moderate Concern	Strong Concern
Picky Eater
Tags or Clothes Irritate
Allergies (dark circles under eye)
Frequent colds/Sinus Infections
History of Ear Infections
Phobias
Tics
Overly Sensitive to Odors
Overly Sensitive to Tastes Food Textures
Overly Ticklish
Reactions to Vacinations
Overly Sensitive to Sound
Perseveration (endless repetition)
Hyperactive (high activity level)
Hypoactive (low activity level)

Indicate the level of concern for the individual's abilities in the following areas:

The individual is:

Individual's reading level is:

Individual's math level is:

Rate mastery of math facts:

Is the individual taking any medications?

Does the individual take nutritional supplements? i.e. probiotics, multi-vitamins, individual supplements like Vit B-6... Please list below:

Indicate your main reason(s) for this consultation:

Please let us know any other information you think would be helpful for the discussion about this individual:

Do you, the individual mentioned in this survey or anyone you know experience health challenges in any of these areas?