Pediatric New Client Form Page 5
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Complementary or Alternative Healthcare Professionals Consulted
(Check all that apply and provide name, address, and telephone of each)
Osteopath ________________
Craniosacral Therapy
Nutritionist _______________
____________________________
___________________________
___________________________
____________________________
___________________________
___________________________
Chiropractor ______________
Homeopathy _____________
Massage _________________
___________________________
___________________________
____________________________
___________________________
___________________________
____________________________
Feldenkrais ______________
Other __________________________________________________
___________________________
__________________________________________________________
___________________________
__________________________________________________________
DEVELOPMENTAL HISTORY
(Please note approximate age in months for each)
Rolled Over: _____ stomach to back
_____ back to stomach _____ for locomotion
Sitting:
_____ stayed sitting when placed
_____ got self into sitting position
Crawling: _____ on belly
_____ rocking on hands & knees
_____ creeping on hands & knees
Standing: _____ held weight _____ stayed up when placed
_____ pulled self up to stand
Walking:
_____ stepping with hands held _____ cruising around furniture _____ steps without support
_____ walking independently more than 10 steps
Never Rarely
Occasionally Frequently
Walking on toes:
Jumping: _____ in place
_____ over a line
_____ off of step (_____ height) _____ over obstacles
Hopping 3 or more times:
_____ on right foot
_____ on left foot
Never
Rarely
Occasionally
Frequently
Falls:
Baby Devices Used: (age in months & estimated hours per day)
Sling ________
Swing ________
Exersaucer ________
High Chair ________
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