Parent/Client
Registration
Please
print, fill out and/or contact
us for registration info
Client
Name_______________________
Address__________________________
_________________________________
Phone
number____________________
School/workplace_________________
Reason
for signing up for our programs
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Any
prior testing_________________ Any medications related to learning
_____________________________________________________________
Do
you have a program or package that
you would prefer?
____________________________________________________________
Do
you have financial restrictions?
____________________________________________________________
When
would you like to have your program completed
by:________________________
Do
you need insurance codes?__________
Checkmark
for yes X for
no DNA for does
not apply
____(!
1.)
Hypoglycemia
(Low
Blood sugar)
Low blood sugar can stem from thyroid disorders, liver or pancreatic problems,
or adrenal gland abnormalities, or even an insufficient diet. Hypoglycemia can
display the same ADHD like symptoms.
___.(!
2.)
Allergies:
15 to 20 percent of the world has some type of allergy. A person can be
allergic to nearly anything so check for all forms. Food is one of the primary
causes of allergic reactions. If a child eats food they are allergic to, the body will not run
properly and that may affect behavior. Everyone has different sensitivities to
allergens so just because you aren't affected does not mean your child won't
be also. (Some
examples, Allergic reactions to food dye, milk, chocolate, and grains, etc.)
If testing ask for a saliva test for food sensitivities too.
____3.(!
3.)
Learning
disabilities: If
the primary place of behavior problems is at school, learning disabilities may
be the cause of ill behavior. One of the main things that affect a child's
self-esteem is how well they do in school. If a child has an undiagnosed
learning disorder that makes school much harder and sometimes impossible.
Children with undiagnosed learning disabilities are labeled as lazy, stupid,
and many other downgrading opinions that affect self-esteem. And many times
when a child's self-esteem is at jeopardy they try to make up for it in other
sometimes-nonproductive ways such as acting out, bullying, or becoming the
class clown.
Outcome/diagnosis____________________________________________
What testing was given_________________________________________
Who
diagnosed _____________________________(Pediatrician, private counselor, Psychiatrist,
school system etc)
4.(!
4.)
Hyper
or hypothyroidism:
An
imbalance in metabolism that occurs from an overproduction or underproduction
of thyroid hormones. This imbalance may cause a variety of behaviors and may
affect all body functions.
____(!
5.)
Hearing
and vision problems:
If a child can't see or hear properly, school and daily things in life are
nearly impossible and it may cause ADHD like symptoms especially in
educational settings.
Date of last vision check___________
Date of last
hearing check___________
*Other
good possibilities to check for
____(*1.)
Spinal
Problems:
Some spinal problems can cause ADHD like symptoms because if the spine is not
connected to the brain properly nerves from the spinal cord can give the brain
all of signals at once making a child rambunctious and always on the go.
____(*2.)
Toxin
exposures:
Children are more vulnerable to toxins than adults. Such as
pesticide-poisoning (Eating vegetables and fruit not washed thoroughly, they
can be exposed to them by playing outside on the ground), also by gasoline
fumes, and herbicides. Inside there are also many toxins. Disinfectants,
furniture polishes and air fresheners are toxins that can affect some
children's behaviors. Beds and carpets are one of the most dangerous places in
the house because they are full of different types of dust, and other toxins.
Toxins can cause hyperactivity, attention deficits, irritability, and learning
problems.
____(*3.)
Carbon
Monoxide poisoning
:
Thousands of children each year are exposed to toxic levels of this gas each
year. Sources include gas heaters, and other gas appliances such as
fireplaces, dryers, and water heaters.
____.(*4.)
Seizure
disorders:
The
most overlooked is the absence Seizures. During an absence seizure, the
brain's normal activity shuts down. The child stares blankly, sometimes
rotates his eyes upward, and occasionally blinks or jerks repetitively, he
drops objects from his hand, and there may be some mild involuntary movements
known as automatisms. The attack lasts for a few seconds and then it is over
as rapidly as it begins. If these attacks occur dozens of times each day, they
can interfere with a child's school performance and be confused by parents and
teachers with daydreaming.
You
should not use light and sound and hemi-sync products if there is a risk of
seizure-You must agree to be in the center during all sessions/services
____11.(*5.)
Metabolic
disorders:
They
reduce the brain's supply of glucose, the bodies fuel and can cause ADHD like
symptoms.
_____12.
(*6.)
Genetic
defects: Some
mild forms of genetic disorders can go unnoticed in children and display some
of the same symptoms of ADHD. Mild forms of Turner's syndrome, sickle-cell
anemia, and Fragile X syndrome are some examples. Almost any genetic
disorder can cause hyperactivity or other behavior problems, even if the
disorder isn't normally linked to such problems. Many genetic diseases disrupt
brain functions directly, through a variety of paths. A simple blood test can
rule out genetic disorders.
Condition
and short explanation_____________________________________________________
____13.(*7.)
Sleeping disorders
or other problems causing fatigue and crankiness during the day.
____14.(*8.)
Post-traumatic
sub clinical seizure disorder:
It
causes episodic temper explosions. These fits of temper come out of the blue
for no reason. Some of these seizures can be too subtle to detect without a
twenty-four-hour electroencephalogram (EEG).
____15.(*9.)
High
mercury levels:
One
of the most interesting things regarding high mercury levels is that it can
relate to dental fillings. Children who have mercury amalgam fillings in their
mouth and grind their teeth are at risk of high mercury levels. American
dental associations are defensive on the subject of mercury fillings but many
European countries have discontinued the use of them because of side effects.
There are also other causes of high mercury levels.
____16.(*10.)
High
manganese levels
____17.(*11.)
Iron
deficiency:
Iron
is an essential component of hemoglobin, the oxygen carrying pigment in the
blood. Iron is normally obtained through the food in the diet and by the
recycling of iron from old red blood cells. The causes of iron deficiency are
too little iron in the diet, poor absorption of iron by the body, and loss of
blood. It is also caused by lead poisoning in children.
____18.(*12.)
B
vitamin deficiencies:
Many
experts believe that one of the main causes for inattention, hyperactivity,
impulsivity, temper tantrums, sleep disorders, forgetfulness, and aggression
are caused by faulty neurotransmissions a problem with the
neurotransmitters in the brain. Vitamin B-6 is a necessary vitamin used in the
making of neurotransmitters that affect behavior. A lack of this vitamin or
really any other vitamin can cause a child to act inappropriately.
____19.(*13.)
Excessive
amounts of Vitamins: Excessive
amounts of vitamins can be toxic to the body and may cause the same ADHD like
symptoms. It is possible to overdose when taking vitamins so make sure you
contact a physician and check for vitamin deficiencies before taking extra
vitamins.
____20.(*14.)
Tourette's
syndrome:
Tourette's syndrome is a rare but disruptive condition. It involves multiple
tics (small, repetitive muscle movements), usually facial tics with grimacing
and blinking. Tics may also occur in the shoulders and arms. This is usually
accompanied by loud vocalizations, which may include grunts or noises, or
uncontrollable (compulsive) use of obscenities or short phrases. The tics are
worse during emotional stress and are absent during sleep. The cause is
unknown. It occurs most often in boys, and may begin around age 7 or 8 or not
until the child is in his or her late teens or early twenties. It may, at
times, run in families. This disorder can be mistaken for not being able to
sit still or impulsive behavior.
____21.(*15.)
Sensory
Integration Dysfunction:
Sensory Integration Dysfunction is the inefficient neurological processing of
information received through the senses, causing problems with learning,
development, and behavior. These children are over-sensitive or
under-sensitive dealing in touch, taste, smell, sound, or sight. For example,
some of these children crave or avoid fast and spinning movement, such as swinging,
rocking, twirling, and riding the merry-go-round- without getting dizzy. These
children may move constantly, fidget, enjoy getting into upside down positions
and be a daredevil. These children may become overexcited when there is too
much to look at. They may cover their
eyes, have poor eye contact, be inattentive when drawing or doing desk work,
or overreact to bright light. These children often act out in an attempt to
cope with their inability to process sensory information such as acting out in
crowded or loud places.
____22.(**1.)
Early-onset
diabetes:
Symptoms
include aggression, depression, and anxiety. If you have a family history of
diabetes checking for this is a must.
____23.(**2.)
Heart
disease:
It affects blood and oxygen flow to the brain affecting brain function that
in-turn affects behavior.
____24.(**3.)
Cardiac
conditions:
It can reduce the supply of blood, oxygen and nutrients to the brain.
Defective blood vessels between organs to the brain.
____25.(**4.)
Early-Onset
Bi-Polar disorder:
Also
know as child-like Bi-polar. The experts state that 85% of children with
child-like Bi-polar also meet the criteria for ADHD. The symptoms are
extremely close. Most people when they think of Bi-polar disorder, think of
Adult like Bipolar which mood swings happen over a somewhat long period of
time. In child-like Bipolar, the mood swings can happen many times within a
twenty-four hour day, known as rapid cycling. At one moment they're calm and
the next minute they could be in a full fledge temper tantrum. Some of the
symptoms are Distractibility, Hyperactivity, impulsivity, separation anxiety,
restlessness, depressed mood, low self-esteem, and many more.
Early-Onset Bi-polar should be ruled out before ADHD is considered mainly
because they are treated with different medications if you choose
medications that is. ADHD is treated with stimulant medications which will
make a Bipolar child worse possibly psychotic.
____26.(***1.)
CAPD
(Central
Auditory processing Disorder) will
sometimes occur in children who have had a history of ear infections and/or PE
tubes. Symptoms include distractibility, inability to follow a set of verbal
instructions, "space out", etc.
____27.(***2.)
Worms:
Such
as Pinworms lay their eggs in the anal area, causing tickling and itching,
which are most bothersome at night. The lack of sleep from this type of
infestation can cause crankiness or bad behavior during the day. When asleep,
nightmares may be present. This problem is mostly found in very young children
preschool to kindergarten because of primitive toileting skills, they tend to
put their fingers in their mouths, and they participate in a lot of hands-on
activities with other kids and with pets. Roundworms, hookworms, and tapeworms
are other examples that can make a child display ADHD like symptoms. Worms
cause hyperactive behavior, learning problems, depression, or attention
deficits by making children miserable on the inside.
____28.(***3.)
Viral
or bacterial infections:
When a child is affected by an infection that might cause problem behavior.
Let
us know at all times if your child is on antibiotic as it affects there
performance
____29.(***4.)
Malnutrition
or improper diet:
Many
children in the United States do not eat a well balanced diet. A proper diet
is necessary to growing children. An improper diet can affect a child's
behavior in an ill way.
____30.(***5.)
Head
injuries:
Such
as the post concussion syndrome. Some of the symptoms include Irritability,
emotionality, memory problems, depression, and sleep disturbances. A
concussion can disrupt brain functioning causing ADHD like symptoms.
____31.(***6.)
Dietary
Factors:
(For
example to much caffeine and sugar)
At
doses as low as 250 milligrams a day, a level many American children exceed-
caffeine can cause rambling speech, attention and concentration problems,
agitation, heart palpitations, insomnia, and hyperactive behavior. In a way,
it is true we are what we eat.
____32.(***7.)
Some
disorders such as anemia
reduce oxygen to the brain causing disturbance in the brains chemistry causing
ADHD like symptoms.
____33.(***8.)
Fetal
alcohol syndrome
(FAS)
or Fetal alcohol effects (FAE):
FAS
is a name that doctors use to describe the damage done to children's brains
and bodies when their mother drink heavily during pregnancy. It is the leading
form of mental retardation today. Prenatal alcohol impairment, however, also
comes in a milder form called fetal alcohol effects (FAE). Children with FAE
often don't look disabled, and they tend to score in the low-normal or even
normal range of intelligence. But these kids aren't normal. Their
mal-developed brains cause them to exhibit a wide range of behavior problems,
including hyperactivity, attention problems, learning disorders, and ethical
problems such as stealing, lying, and cheating.
____34.(***9.)
Intentionally
or unintentionally sniffing materials
such
as modeling glue or other house hold products.
____35.(***10.)
Some
drugs:,
(both
prescription and illegal)
can cause the brain to atrophy, leading to disturbed cognition and behavior.
If your child routinely takes prescription or over-the-counter medications for
asthma, hay fever, allergies, headaches, or any other condition, consider the
possibility that the drugs are causing or contributing to behavior problems.
The effects of antibiotics on attention span are being studied at this time.
When this is the case, the effects go away as the antibiotics are
discontinued.
____36.(***11.)
:A
beta-hemolytic streptococcus: better
known as "strep.") Although
these bacteria are most commonly thought of as the cause of strep throat. Left
untreated, strep can cause rheumatic fever and a movement disorder called
Sydenham's chorea. Moreover, recurrent infections can lead, in susceptible
children, to a group of symptoms collectively known as PANDAS (Pediatric
autoimmune neuropsychiatric disorders) Some symptoms of PANDAS include
obsessive-compulsive behavior, Tourette's syndrome, hyperactivity, cognitive
problems, and fidgeting.
Let
us know at all times if your child is on antibiotic as it affects there
performance
____37.(***12.)
Lack
of exercise:
"Hyper
Couch Potatoes" are children who aren't moving enough. Some children
because of lack of exercise may seem as though they are always in motion, but
often that motion is in fits and spurts: leaping up from a chair, spinning
around in the lunch line, bouncing in a chair while watching TV. Quite a few
hyperactive children actually do not get enough sustained, strenuous exercise
to stay healthy mentally and physically. Exercise can make people happier,
less anxious, less hyperactive, and less depressed. One reason is that
exercise increases serotonin levels in the brain exactly what Prozac,
Elavil, and similar drugs do.
____38.(***13.)
Gifted
Children:
Gifted children often display ADHD like symptoms because most of the time they
are bored with what other kids their age are doing. Behaviors associated with
Giftedness are poor attention, boredom, daydreaming, low tolerance for
persistence on tasks that seem irrelevant, their judgment often lags behind
their development of intellect, their intensity may lead to power struggles
with authorities, and they may have a high activity level. They may need less
sleep compared to other children, and they may question rules, customs, and
traditions. If your child scores above average on IQ tests, aces exams, has no
trouble with homework, has no apparent learning disabilities, and primarily
exhibits his or her problems mostly at school, maybe seeking a more
challenging class or school would help.
____39.(***14.)
Emotional
problems:
Those
who are experiencing emotional problems, like depression, most often display ADHD like symptoms.
Please
explain briefly__________________________________________________________________
