Welcome back.

Quick verification before we get into your child's history. This information helps Dr. Levine write a thorough diagnostic report and prepare for your visits.

Patient last name *

Patient date of birth *

State *

Your child's current providers.

Anyone currently caring for your child medically, therapeutically, or educationally. We'll request relevant records and, with your permission, share findings post-evaluation.

My child does not currently see any medical or therapy providers.

Organization or practice name *

Type *

Provider name (optional)

Phone *

City *

State *

This is my child's primary care provider I received a referral from this provider Authorize Foyer to share the diagnostic report with this provider after the evaluation

Your child's medical history.

Anything diagnosed, treated, or under investigation. We've trimmed this to what's clinically relevant for an autism evaluation.

My child has no significant medical history to report.

Evaluations & therapies.

Anything formal your child has been through. Helps us understand what's already known.

Surgeries, allergies, medications.

Three quick sections. Skip what doesn't apply using the opt-outs at the top.

Surgeries

My child has not had any surgeries.

Allergies

My child has no known allergies.

Allergy *

Reaction *

Medications

My child does not currently take any medications.

Current medication *

Includes prescription, over-the-counter, vitamins, and supplements.

Pregnancy and birth.

Anything that applies. It's okay if you don't know all the details.

Birth history is unknown or unavailable.

Your child's developmental story.

The most important section. This is the foundation of Dr. Levine's clinical thinking, so take a moment with these questions.

Milestones

Approximate ages are fine. Select "Not yet" or "Unknown" if you're unsure.

First wordse.g., mama, dada, ball

Combining two wordse.g., "more milk"

Responds to their name

Points to objects of interest

Engages in pretend playe.g., feeding a doll, "talking" on toy phone

Walking independently

Toilet trained (daytime)

Regression

Has your child ever lost skills they previously had? *

Yes

No

Anything we missed?

Anything else you'd like Dr. Levine to know going in? (optional)

✓

Medical history complete.

Dr. Levine will review your child's history before your first visit. You'll receive a calendar invite and a video link 24 hours before the appointment.

If anything significant changes before your visit (new diagnosis, medication change, recent injury), you can update your medical history anytime by signing back into your account.

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