Language
  • English (US)
  • Initial Intake Form

    PATIENT HISTORY AND BACKGROUND
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    • BIRTH & MEDICAL HISTORY 
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    • Breastfeeding and Lactation  
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    • PRGENANCY

    • FEEDING HISTORY:

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    • BABY HISTORY

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    • If your baby has a surgical release of their tongue tie, lip tie, or buccal/cheek ties please answer the following:

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    • PARENT HISTORY

    • SPEECH LANGUAGE  
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    • FEEDING 
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    • OCCUPATIONAL HISTORY 
    • CHILD PROFILE (FINDINGS) 
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    • SENSORY PROCESSING 
    • SENSORY PROCESSING SYSTEMS 
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    • FUNCTIONAL ACTIVITIES (Exploring environments, play, leisure, school and daycare) 
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    • EDUCATIONAL/THERAPY HISTORY 
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    • Clear
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    • Should be Empty: