Baseline AssessmentHello! Please complete the below assessment. This is a powerful tool that provides insight into the health of your nervous system. Please review the below sections and mark a check beside all that you have experienced from childhood to present day. Learning Poor memory Language delays Easily distracted Difficulty concentrating Learning disability (Dyslexia, ADHD, etc.) Poor executive brain function (difficulty to focus, follow directions, and handle emotions) Difficulty with logic/reasoning Lost interest in school Disrupts class Immune System Asthma Allergies Frequent/Prolonged illness Auto-immune problems (cancer, diabetes, lupus, etc.) Headaches, stomachaches, join pains, fatigue Severe reactions to minor infections Food intolerances Skin conditions Sensory Integration Lack of social skills Tics - constant movement Fussy about textures Trouble with non-verbal cues Fearful of crowds, strangers, new environments, and altered routine Developmental delays Insensitive to touch/pain Light/sound sensitivity Clumsy/poor coordination Emotions Anxiety Moodiness Feeling helpless Develops physical symptoms in response to emotional issues Social phobia/other phobias Inappropriate feelings Recurrent thoughts Inability to sleep Depression Behaviour Impulsive Aggression Cannot follow instructions Bites nails, picks or cuts skin Temper Tantrums/Meldowns Reckless, cannot control actions Cannot sit still Damages property Eating disorders Withdrawal Personality Defiant Overly self-conscious Detached from family No care for consequences Unable to handle disappointment Lack of respect to parents and/or teachers Difficulty making friends Distorted thinking Deceitfulness Anti-social Please write a paragraph about your circumstance. Include any concerns you may have regarding your health, and how it effects/interferes with your daily quality of life. more space if needed.... Patient Name * First Name Last Name Parent name (if applicable) First Name Last Name Patient Age Email * Phone (###) ### #### Anything else you would like to add... Congratulations! You have just made a huge accomplishment — taking the first step. I’m honored to be with you on this journey and look forward to taking care of you. — Sarah
