Pre-appointment Questionaire: CranialWe are excited to meet you in person. We know our little ones can get fussy so we try to make our appointments as efficient as possible. Please complete the following questionnaire to keep your appointment as smooth as possible... Patient Name * First Name Last Name Email * Phone * (###) ### #### How were you referred to our clinic? * Yes No Still Unsure Who is your child's pediatrician? BIRTH HISTORY: Please describe any pertinent information regarding to the birth of baby (ie forceps or suction used, breach or unusual positioning, premature, NICU stay) Delivery Vaginal C-section Is baby a Multiple (twin, triplet, etc) What was baby's weight at birth? MILESTONES CURRENTLY MET: Please check all that apply. Baby can: Rolling Back to Belly Rolling Belly to Back Sitthing with assistance Sitting independently Getting onto hands and knees Crawling Pulling to Stand Walking What position does baby sleep in? Check all that apply: On their Back On their Tummy On their Side Do you have any concerns about milestone achievements or developmental delays? MEDICAL CONCERNS Does baby have any history of the following concerns: Tongue-Tie Torticollis Skin Sensitivities Troubles with feeding Hip Displasia Acid Reflux Chronic Ear Infections Are there any other medical considerations that should be noted? HEAD SHAPE CONCERNS What are your primary concerns with head shape? Describe how you have working to prevent baby's head shape from getting worse? When did you first notice head flatness? Has any imaging (x-ray, CT, MRI) been done on baby's head? Yes No Baby will likely need a helmet. Please select the level that you agree in your own opinion. Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you so much for taking the time to fill out this questionnaire, it is extremely helpful to have this information ahead of time.
