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Who referred child for occupational therapy services?
1. Please describe your child’s birth history. List any complications during pregnancy, birth or infancy.
2. Please give the approximate ages that your child accomplished major developmental milestones. Please include sitting independently, crawling, walking, reaching, talking, etc.
3. Please describe any developmental challenges your child has faced or continues to face.
Please use the following scale to describe your child.
1. Never or rarely exhibits this behavior
2. Occasionally exhibits this behavior
3. Exhibits this behavior as much as typical for a child of this age
4. Exhibits this behavior somewhat more than expected
5. Very frequently exhibits this behavior
10. Does your child have a history of ear infections? If yes, please describe the frequency of occurrence and how the ear infections have been medically treated.
11. Does your child have any allergies? If yes, please list what your child is allergic to, how these allergies are medically managed and any behaviors your child exhibits that you think are related to the allergies of the allergy medications.
12. Does you child currently take any medications? If yes, lease list the medications, dosages and for what condition the medication is taken. Also, please list any behaviors your child exhibits that you believe might be attributed to the medication.
Check any of the following with whom you had contact concerning your child. (give name and address).
PsychologistPhysical TherapistSpeech TherapistNeurologistResource or Special Teacher
Has your child had any formal evaluations/testing? If so, what and when?
13. In your own words, describe your child’s general level of motor coordination. Include types of motor experiences your child enjoys, your child’s independence in initiating motor experiences, hos much assistance and supervision your child needs during motor play, etc.
14. In your own words, please describe your child’s balance skills.
1. What do you see as your child’s strengths?
2. What are your concerns about your child?
What have you been told by doctor, teachers, and/or others about your child’s abilities and needs?
4. What do you hope will be gained by having your child seen at this clinic?