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Your Name

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Email Address

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Pregnancy & Birth History

These early experiences can impact nervous system development

High stress during pregnancy

Pregnancy complications

Medications during pregnancy

Premature birth

C-section delivery

Vacuum/forceps delivery

Prolonged labor (12+ hours)

NICU stay

Early Life Challenges

First-year stressors that shape nervous system function

Colic (3+ hours crying daily)

Reflux/frequent spit-up

Feeding difficulties

Severe sleep issues

Chronic constipation

Multiple antibiotics (first year)

Recurrent ear infections

Torticollis/head preference

Immune & Gut Health

Signs of nervous system-immune system dysregulation

Frequent illnesses (6+ per year)

Food allergies/sensitivities

Eczema or skin issues

Asthma or breathing issues

Chronic digestive problems

Extreme picky eating

Autoimmune condition

Severe seasonal allergies

Behavioral & Emotional Patterns

How dysautonomia shows up in behavior and mood

Frequent meltdowns/tantrums

Anxiety or excessive worry

Extreme mood swings

Oppositional behavior

Severe separation anxiety

Sensory processing issues

Social interaction struggles

Poor emotional regulation

Focus & Learning

Cognitive and developmental indicators

Attention/focus difficulties

Hyperactivity/restlessness

Impulsive behavior

Reading/writing struggles

Delayed milestones

Speech/language delay

Poor coordination

Memory difficulties

Current Health Status

Ongoing challenges and medical history

Currently on medications

In therapy/counseling

Has IEP or 504 plan

Chronic pain/headaches

Chronic fatigue

Recurring infections

Has diagnosis (ADHD, autism, etc.)

Sees multiple specialists

Family & Lifestyle Factors

Environmental factors affecting nervous system health

Family history of conditions

High household stress

Excessive screen time

Poor sleep quality

Highly processed diet

Limited physical activity

Significant trauma/stress event

Known toxin exposure

Perfect Storm Assessment | Alive & Free Chiro

The Perfect Storm Assessment