Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Phone *

(###)

###

####

Child's Name *

First Name

Last Name

Child's birthdate *

MM

DD

YYYY

Currently Pasha is only accepting female adult clients and children in her practice. Please check if you have read and understand this statement. *

Yes, I understand.

Please indicate any conditions that you/your child have had or currently have: (check all that apply) *

allergies/sensitivities

food allergies/sensitivities

headaches/migraines

anxiety

ADD/ADHD

Autism Spectrum Disorders

abnormal skin conditions, rash, etc

heart/circulation problems

birth trauma

latch problems

tongue retraction

arching

breast preference

asymmetries

suck problems

cephalhematoma

tongue, lip, buccal tie

tongue tie revision

cranial asymmetries

overrdiding cranial bones

inadequate milk transfer

digestive disturbances

nervous system depression

nervous system irritability

torticollis

postural body twist

nipple trauma/pain

inefficient/inadequate suckling

poor seal

lengthy feedings

sucking or clicking sounds during feed

failure to thrive

sensory overwhelm

trouble with impulse control

explosions/tantrums

withdrawing/hiding

trouble keeping their body still, focusing

none of the above

other

Women's Health History: please check all that apply

Please describe the mother's health history to better inform the history of the child.

painful or irregular periods

birth control (current/previous)

IUD (current/previous)

previous pregnancy

current pregnancy

previous birth(s)

miscarriage

abortion

pelvic pain

PMS

PMDD

prolapse

hysterectomy

pelvic surgery

n/a