Name Email Child's Name Home Address City State Zip Date of Birth Current Age Mother's Name Mother's Cell Father's Name Father's Cell Brother's Name(s) and Age(s) Sister's Name(s) and Age(s) Pediatrician's Name Pediatrician's Number Weight at Birth Length at Birth Comments on labor and delivery: What is the diagnosis of your child at present? What was the doctor’s original prognosis for your child? What are the physical symptoms of the disability? Does your child have convulsions? What medications does your child receive? Does your child have a problem with his/her spinal column? Yes No In what area? Has your child undergone surgery? Yes No Please describe, what dates Does your child have a cardiac problem? What other treatments or therapies has your child undergone? (Please specify when and for how long) Is your child’s motor development delayed? (Please describe) How would you describe your child’s concentration, attention span, and general awareness? Would you characterize your child as: happy passive introverted aggressive excitable extroverted easy going depressed sensitive to sound enthusiastic sensitive to touch How would you describe your child’s relationship: (Be specific) With other family members? With friends/peers? Please describe the attitude of each family member toward your special child: Do you have any evaluations by teachers, doctors or therapists, including letters and reports which might assist me in helping your child? Name of your child’s current school: Have any family members practiced yoga? How did you hear about yoga therapy, and what goals do you hope your child will achieve by participating in this program? Submit Δ
