Shannon Sciametta
info@shannonsciametta.com | TEXT (516) 473-3968
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Holistic Supplementation Intake Form
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Mother’s First & Last Name:
*
First
Last
Father’s First & Last Name:
*
First
Last
Address
Phone Number
Child's Gender
Child's DOB
Child's weight:
Mother's Current Health
Father's Current Health
List any complications during pregnancy or after delivery
Gestational age at delivery (how many weeks pregnant)
Vaginal or Cesarean?
Delivery type:
Vaginal
Cesarean
Was your child breastfed? If so, how long?
If formula fed, what formula was used?
Was your child fully vaccinated according to schedule?
Yes
No
How was your child’s first year of life? Did they meet developmental milestones (rolling, crawling, walking, speech)? Please explain
Did your child ever experience a regression? If so, when, and what skills were lost?
What traditional therapies has your child participated in and were they helpful?
How is your child’s sleep?
How are your child’s digestion and bowel habits? Please list frequency and texture of bowel movements:
How is your child's diet, are they currently on any restrictive diets or trialed any in the past? Are they a picky eater? Please list a sample of days diet.
Does your child have self stimulatory or repetitive behaviors? Is so, please list below:
Is your child in school?
Yes
No
If yes, what grade?
Are they receiving accommodations or have an IEP? How are they doing in school?
Please list all of your child’s current supplements, including dosages:
Can your child swallow capsules?
Yes
No
Which supplement forms do you prefer?
Liquid
Capsules
Chewable tablets
Gummies
Other
Parent/Guardian name
Submit
