Child History The Melillo Child History Form Consent* Yes No I consent that I am freely providing this information about my child for the purposes of diagnosis and/or treatment by Dr. Jeri LaVigne and that all information that is being collected will not be shared with anyone other than Dr. LaVigne and her staff.Child's Name* First Last Age:*Date of Birth:* Month Day Year Mother’s & Father’s Name:*1. Formal Diagnosis?*2. Chief complaints in order of importance (1-5)*3. Pregnancy and Delivery Complications?*4. Breast feeding in hospital was formula supplemented?*Any issues early on?* Sucking? Illness? Eczema? Other? Please describe other issues.*5. Development at home, breast fed? When was food supplemented? Any dairy based products introduced? And problems with feeding, reflux etc.?*6. Any immune issues, first or now?* Eczema? Asthma? Allergies? Infections? 7. Any sleeping issues first or now?*8. Parents relationship, married, live together?*9. Developmental milestones? When did they walk alone? When did they talk? How many words do they speak now?*10. Verbal vs. Non-verbal communication? Eye contact, joint attention? Do they look in a mirror? Recognize or know body parts? Do they care about their appearance, clothes etc.?*11. Do they have friends, do they play with other kids? Where are they in school, what grade?*12. Do they know* Letters? Numbers? Colors? Shapes? 13. Do they read at all? Can they do Math? Do they* Write? Color? Draw? 14. Is there any learning disability in school? What are the most difficult subjects?*15. What are the best subjects for the child?*16. Any emotional issues, tantrums etc.?*17. Any major sensory issues, hyper, hyposensitivities?*18. Do they feel pain?*19. Are they a picky eater? Any food preferences? What do they drink?* Gluten Free Dairy Free Soy Free Other Please describe.*20. Do they have a sense of smell or taste?*21. What does muscle tone and motor activity look like? What is hand, foot dominance? When?*22. Any obvious balance issues, motion sickness, afraid of high places? Does she spin herself, get dizzy?23. Any stims or tics? Any OCD behaviors?24. Any unusually strong skills?* Early reading? Memorizing songs? Memory for details? Memory for locations? Other? Please describe.*25. Bowel movements, toileting issues Before and Now?*26. Parents jobs, personalities* Extrovert Introvert Creative Logical Linear Other Please describe.*27. Any family or genetic history of Physical or mental health issues, learning challenges?*28. What does the child like to do during the day for playtime? How much computer screen time?*29. Do they prefer to be outdoor or indoors?*30. What treatments or tests?* Blood Tests? MRI? Genetic? Metabolic? EEG? IQ? Allergy? 31. Has any treatments helped? What has been the most effective?*32. How did they come aware of my work? Have they read Disconnected Kids? Have they tried any of the treatments or therapies and if so, describe?*CAPTCHA Δ Contact Contact Dr. Jeri 678-886-5996 Dr. Jeri LaVigne Address 6284 Hunting Creek Rd NEAtlanta, GA 30328 Privacy Policy
