Tomatis Patient Intake Form – Child Form
Is the child living with?
Are there any other relatives living with the family?
REASON FOR CONSULTATION
BIRTH HISTORY (If your child was adopted, please answer the following questions.)
Language(s) other than English spoken during the pregnancy? (Please add NA if not applicable)
Were there any complications, illnesses, or stresses during the pregnancy?
Where there any miscarriages before this pregnancy?
Was your child born full term?
Birth type
Was labour/ delivery difficult?
Did your child receive antibiotics at birth?
Was your child in the NICU (Neonatal Intensive Care Unit)?
Select all that apply to your child before discharge.
Has your child ever been diagnosed with gastro oesophageal reflux?
Did your child spit up/ vomit?
Newborn hearing screening?
DEVELOPMENT HISTORY
Has your child received any other interventions or therapies?
Has your child been diagnosed with a visual impairment?
Does your child wear glasses?
Has your child been diagnosed with an auditory impairment?
Did your child crawl?
Which hand does your child favour?
Which leg/ foot does your child favour?
Does your child like to swing?
Is your child sensitive to fabrics/ textures?
Tags in clothing?
Is your child overly sensitive in general?
Is your child irritable?
Does your child have good eye contact?
Does your child follow faces or objects?
Does your child like to play with?
Does your child exhibit the following behaviours?
Has you child been in any accidents?
Has your child ever been hospitalized?
Has your child had any of the following procedures?
Does your child have a diagnosed seizure disorder?
Is your child monitored by a doctor?
ENT HISTORY (Please select all necessary, Does your child do any of the following?)
Does your child have any of the following:
Has your child had any problems with their tonsils or adenoids?
Does your child present with any of the following conditions (select all that apply)?
Is your child overly sensitive to loud sounds or noises?
Does your child hear sounds others don’t, or before others notice?
Is your child able to pay attention in a noisy environment?
Is your child’s language hard to understand?
Does your child mispronounce words?
Does your child frequently ask you to repeat what you said?
Does your child rarely participate in conversations?
Does your child need visual cues to respond to verbal instructions?
Does your child seem to not hear the beginning or middle of statements?
Does your child cover his/her ears to avoid auditory input?
Does your child “tune out” or ignore sounds from the environment?
Does your child hum, sing softly, or self-talk through these tasks?
Is your child’s voice volume too loud?
Does your child respond when his/her name is called?
Is your child slow or delayed in responding?
Does your child enjoy making strange noises or repetitive sounds?
Does your child have difficulty in using proper words?
Does your child have a limited use of descriptive vocabulary?
ALLERGIES/SENSITIVITES (Please select all necessary)
Does your child suffering from food or environmental allergies or sensitivities?
Has your child ever been tested for allergies?
Has your child ever suffered from eczema?
Asthma?
Other rashes?
Yeast infections?
Does your child suffer from gut issues?
Does anyone in your family suffer from any allergies or food intolerances?
ORAL MOTOR HISTORY
Does your child drool?
Is brushing teeth difficult?
Does your child currently mouth objects?
Did he/she do it in the past beyond what is age appropriate?
Does your child currently use a pacifier or suck his/her thumb?
Did he/she in the past, beyond what is age appropriate?
SLEEPING HISTORY
Where does your child sleep?
Does your child have difficulties with falling asleep?
Does your child sleep through the night?
Does your child wake at night?
Does he/she need a light to fall asleep with?
What activities do you use to get your child back to sleep?
Does your child sleep during the day?
Which activities do you use as a part of your child’s bedtime routine?
What does your child do when he/she awakens?
FEEDING
Was your child breastfed?
Did your child attach well to the breast?
Did he/she wean him/herself?
Have you ever forced your child to eat?
Is your child a pick/fussy eater?
Does your child have a reduced appetite/limited intake?
Is your child not progressing to age appropriate foods?
Is your child showing an appetite and then refusing to eat?
Does your child suffer with;
GOALS