Help Me Help You ~ Assessment

First name of Parent

Last name of Parent

Email

Phone

Country/Region

Address

City

Zip / Postal code

Time Zone

Child's name

Childs gender

Male

Female

Is your child left or right handed (if you know yet)

Right

Left

ambidextrous

Unknown

Birthdate of Child (or family member who has the symptoms)

What symptoms are your child having. List all including a diagnosis, and specific location, (right/left) type of pain & level, rashes, sleep, high or low fever, mood...

How is this affecting your child/the family/ school/work/sleep...etc

When did it start? and did it change over time...

Is this a new symptom or ongoing and/or intermittent...explain.

What was happening in your child’s life around the time the symptoms began? (E.g., changes in routine, emotional events, transitions, illness, new experiences, births/deaths..etc.)

Have you noticed any patterns or triggers related to your child’s symptoms? (E.g., certain times of day, activities, foods, interactions, etc.)

Have you sought any treatments or remedies for these symptoms? (E.g., medication, dietary changes, therapies, etc.) If so, what were the results?

How much have you spent so far on remedies/therapies/soultions