LiNC Neurodevelopment Intake Form
Pediatric Form (for < 18 years)

Please complete the following information.  
We will discuss the history and your concerns at length at our upcoming intake visit, so it is ok to be brief on this form.  
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Patient First Name *
Patient Nickname or Preferred Name
Patient Last Name *
Patient Address - Street Address
Patient Address - City 
Patient Address - State
Patient Address - Zip Code
Preferred phone number (xxx-xxx-xxxx) *
Preferred email address *
Patient Current Gender Identity
Clear selection
Patient Sex Assigned at Birth
Clear selection
Patient Date of Birth *
MM
/
DD
/
YYYY
Person completing this form
Clear selection
Primary Medical Care Provider - Name
Primary Medical Care Provider - Street Address
Primary Medical Care Provider - City
Primary Medical Care Provider - State
Primary Medical Care Provider - Zip
How did you hear about our practice or who referred you?
Brief primary concern (we will discuss at length in upcoming visit)
Have you been concerned for more than a few months regarding the following?

[Derived from the Essence Q (Gillberg C 2012)]
Yes
Maybe/A Little
No
General Development
Motor development/milestones
Sensory reaction (eg, touch, sound, light, smell, taste, heat, cold, pain)
Communication/language/babble
Activity (overactivity/passivity) or impulsivity
Attention/concentrating/"listening"
Social interaction/interest in other children
Behavior (eg, repetitive, routine insistence)
Mood (depressed, elated/manic, extreme irritability, crying spells)
Sleep
Feeding
Seizures
Anxiety
Headaches
Movement disorder (eg, tics or tremors)
Other
Clear selection
If "other" concerns, please specify
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