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Intake Form For ReSprout Therapy Reflex Integration Program
Please complete the birth history and present day information form. The form is secure and confidential . The information will only be reported to ReSprout Therapy and will not be shared. 
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Email address
First Name of Child *
Last Name of Child *
Age of Child *
Parent/ Guardian Name *
Child's Date of Birth *
Address
Phone Number *
Seizure history *
Has a diagnosis been given at any time i.e. Dyslexia, ADHD, Autism, Specific Learning Disability, etc...?
Is your child currently taking any prescribed medication? Please specify:
Parent concerns:
Is there any history of learning difficulties in either parent or their families? *
When you were pregnant did you have any medical problems?  Example: high blood pressure, excessive vomiting, threatened miscarriage, severe viral infection, severe emotional stress, etc... please state:
Did you smoke during pregnancy? *
Did you drink alcohol during pregnancy? *
Stress throughout pregnancy
How many weeks gestation was your child at birth? *
My child was born via: (Please check one) *
Required
How many hours were you in labor from first contraction until delivery?
Complications during birth include: (mark all that apply, please add others that are not listed)
Was the birth process unusual or difficult in any way? If yes, please give details
 Please give birth weight if known
In the first 13 weeks of your child's life, did he/she have difficulty in: *
Required
Between 6 months and 18 months, was your child very active and demanding, requiring minimal sleep accompanied by continual screaming? *
Required
My child was rolling over by: *
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My child was sitting independently by *
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Did he/she army crawl or commando crawl? *
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My child crawled at: *
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Describe your child's crawling pattern *
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My child walked at age: *
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Did your child need any kind of therapy? Check all that apply:
How long did your child receive therapy?
In the first 18 months of life, did your child experience any illness involving high temperatures and/or convulsions? If yes, please give details
Was there any sign of other allergic responses? Please list:
Did your child suck his/her thumb or pacifier through the age of 5 years or more? If so, which thumb?
Did your child wet the bed or have toileting issues, albeit occasionally, above the age of 5 years?  Please check as they apply:
Movement & Balance (Please check all that apply)
Motion sickness: Check all that Apply
 Learning to read: Please check all that apply *
Required
Learning to write: Please check all that apply: *
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Telling Time: Please check all that apply *
Required
Riding a bicycle: *
Required
ENT issues: Check all that apply *
Required
At what age was the first ear infection? Please give a detailed history of ear infections: 
Eye-hand coordination: Check all that apply: *
Required
Hyperactivity, movement seeking *
Required
Does your child make numerous mistakes when copying from a book? *
Required
Over-reacts to noise & movement *
Required

Gastrointestinal problems: Has your child regularly suffered from any of the following?

Skin Problems: Has your child suffered from any of the following at regular intervals?
Ear, Nose and Throat Problems: Has your child suffered from any of the following at regular intervals?
Asthma induced by:
Does your child suffer from excessive thirst? *
Required
Do his/her symptoms get worse if he/she has more than a 2-3 hour interval without eating? *
Required
Are there any particular foods which alter his/ her behavior? Please list: *
Auditory Developmental History:
Receptive Listening: This is the listening that is directed outward. It keeps us attuned to the world around us. Do any of the following apply to your child?
The Level of Energy- The ear acts as a dynamo, providing us with the energy we need to survive and lead fulfilling lives. Check as appropriate:
Expressive Listening- This is the listening that is directed within. We use it to control our voice when we speak and sing.
Behavioral and Social Adjustment
Behavioral continued…
Sensory Checklist: Touch
Sensory Checklist: Movement
Sensory Checklist: Body Position
Sensory Checklist: Taste / Smell
Sensory Checklist: Visual
Sensory Checklist: Auditory
Please Tell About Your Child's Sleep Patterns Give Details 
Please add any extra information as necessary:
How did you hear about ReSprout Therapy?
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