Name
Email
Did you experience significant stress during your child's pregnancy? Yes
No
Was your child's birth a traumatic experience for either of you? Yes
Now
Did your baby have unusual body tone? (e.g., holding head up very early and rigidly, or being floppy and lax) Yes
No
Did your baby dislike tummy time or riding in the car seat? Yes
No
Was your child delayed in reaching developmental milestones, or did they skip some milestones? Yes
No
Does your child have sleep problems? Do they breathe through their mouth or sleep with their mouth open? Yes
No
Does your child have a sensitive stomach, experiencing constipation or diarrhea? Yes
No
Is your child's skin sensitive? Yes
No
*For Children Under 1 Year Old* Does your child have irrational fears? Yes
No
*For Children Under 1 Year Old* Is your child clumsy and not well-coordinated for their age? Yes
No
*For Children Under 1 Year Old* Does your child struggle with emotional regulation? Yes
No
*For Children Under 1 Year Old* Have you noticed a lack of eye contact, social awareness, or delayed language development for their age? Yes
No
*For Children Under 1 Year Old* Does your child have difficulty falling asleep, experience night terrors, frequent waking, or sleepwalking? Yes
No
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