Phone Consultation Questionnaire

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?*
Best time to talk (select multiple)*

MondayTuesdayWednesdayThursdayFriday8am- 10am10am- 12pm12pm - 3pm3pm- 6pm6pm- 9pmOther
Name of individual with whom you are concerned:*

First NameLast Name
Individual's age:*
Has the individual been given any learning labels?*

YesNo
If yes, please include labels below:
Hand Dominance

Right handed (when only one hand is needed for a task, the right is chosen)Left handed (chooses left hand for tasks requiring one hand)Mixed handed (switches from one hand to the other for different tasks)

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

	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:*

working at or above grade level for their agehas been held back a grademore than 1 year behind in academics
Individual's reading level is:*

above grade levelat grade levelbelow grade level
Individual's math level is:*

above grade levelat grade level for agebelow grade level

Rate mastery of math facts:*

Is the individual taking any medications?*

YesNo
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?

Low EnergyGut IssuesInflammationSleepHormone ImbalanceImmune FunctionCardiovascular SystemChronic Pain
Should be Empty: