I. Diagnosis:

Reason for referral


Please list any medical diagnoses


Please describe any circumstances surrounding the onset of this problem. (illness, from birth...)


Please list any family history of developmental delays, language delays, or mental health issues (e.g. anxiety, OCD, ADHD).

II. Parent Concerns:

What are the most important issues associated with the client's needs?


What are the client's strengths?


What part of your family's daily routine is most challenging for the client, and why?


What is calming for the client?


What goals would you like the client to achieve in therapy?


Are you willing to participate in therapy sessions when the therapist feels it is appropriate? Are you willing to use therapy strategies at home when appropriate? If no, why?


Has the client previously received therapy? If yes, please list what type of therapy, where, when, and how often they received services?


Is the client currently receiving any other specialized instruction or services? If yes, where and how often? (i.e. cranial sacral, applied behavior approach, horseback riding)

III. Birth History:

Please describe any difficulties associated with pregnancy or birth using the chart and lines below. Include any diagnoses made at birth.


Please describe any difficulties associated with pregnancy or birth using the chart and lines below. Include any diagnoses made at birth.

Birth Details

PrematureOn TimeOver Due
VaginalC-SectionNICU
Labor InducedMultiple Births		Labour Lasted In Hours
Birth Weight In (lbs)	Birth Length	Apgar score
JaundiceIncubator		Intubated (how long)
Feeding difficultyRefluxBreastBottle

IV. Medical History:

Has the client had any serious illnesses or accidents? If yes, please describe and include any hospitalizations and surgeries.


Is the client presently taking medications? Please list medication and reason for administration.


Does the client have any allergies? If yes, please describe.


Is the client on any special diet for nutritional or allergic reasons?


Has the client ever had a seizure? If yes, please describe and list medications and techniques used to control seizures.


Has the client's vision been evaluated? When? By whom?


Does the client have any visual impairment? If yes, please describe the nature and management of the impairment.


Has the client had any ear infections? If yes, how many?


Does the client have tubes in his/hers ears? If yes, for how long? When was the last time the tubes were checked?


Has the child's hearing been evaluated? When? By whom?


Does the client have any hearing loss? If yes, in one ear or both? What degree of loss is it and what frequencies does it cover? Does the client wear hearing aids or have other devices to help him/her hear?


Has the client had any nose, throat or palate disorders (i.e.: clefts), procedures (i.e.: video fluoroscopy) or operations (i.e.: tonsils and adenoids removed)? Please describe below including dates.


Has the client ever had a modified barium swallow study, an upper GI, a pH probe or a gastric motility study? If yes, please give the reasons why, and when the procedure was done, and any results of the procedure.

V. Developmental History:

1. Language:
What is the primary mode of communication for the client (e.g. words, gestures, signs, pictures, AAC device)?



How many words does the client say, or tell us if they are using complete sentences. Please give examples of the words/sentences they use.



What are your concerns about the client's speech sounds? Do you understand the client's words? Do unfamiliar listeners understand the client?



What languages are spoken to the child?
Home:
School:
Does the client have similar problems communicating in the other language(s)?

2. Developmental Milestones:

At what age did the client first accomplish the following:

Developmental Skills	Age	Remarks
Rolled over
Sat alone
Crawled on hands/knees
Pulled to stand
Walked
Babbled
Spoke first word
Combined Remarks-3 words
Began eating pureed baby food
Finger fed
Self-fed (Utensil)
Used a sippy cup
Used an un-lidded cup
Used a straw
Bladder control
Bowel control
Dress self

3. Motor Skills:
Compared to others of the same age and sex, does the client seem to have difficulty:

Motor Skills	Yes	No	Sometimes	Remarks
2. Compared to others of the same age and sex, does the client seem to have difficulty:
manipulating small objects (i.e., buttons, beads)	yes	no	somtimes
Using pencils, crayons, paint-brushes	yes	no	somtimes
Using scissors	yes	no	somtimes
Catching a ball	yes	no	somtimes
Throwing a ball	yes	no	somtimes
Riding a tricycle (if under age 6)	yes	no	somtimes
Riding a bicycle (if over age 6)	yes	no	somtimes
Pumping self on the swing?	yes	no	sometimes
Kicking a ball	yes	no	somtimes

Activity	Yes	No	Sometimes	Remarks
Prefer sedentary activities (i.e., watching TV)	yes	no	somtimes
Prefer fine motor activities (i.e., coloring, building with blocks, beading)	yes	no	somtimes
Prefer gross motor activities (i.e., swinging, running)	yes	no	somtimes
Seek out swinging activities	yes	no	somtimes
Trip over or bump into things	yes	no	somtimes
Prefer indoor activities	yes	no	somtimes
Prefer outdoor activities	yes	no	somtimes

Does/did the client participate in tummy time as an infant? If so, for how long each day?


Please describe any equipment the client is currently using for mobility, self-care, vision, hearing, communication, positioning or splinting.


Does the client's home have any stairs?


Does the client fall often? If so, how many times a day/week?


4. Feeding/Oral Motor:
Does the client have any oral motor difficulties including feeding, speech, or language?


Does the client prefer certain foods or liquids including tastes, textures or temperatures?


Does the client have difficulty with sucking, chewing, using utensils, choking, reflux, swallowing food whole, tooth grinding or drooling?

VI. Social History:

1. Education

Name of School/educational program currently attending:


Current grade level:


Please list any Special Education services, therapy services, or behavioral interventions received at school:


Does the client experience any difficulty in preschool/school? Please describe.


Compared with others of the same age, does the client:

Academic Performance	Yes	No	Sometimes	Remarks
Have poor handwriting	yes	no	somtimes
Make reversals of letters or numbers when writing or copying (if older than age 7)	yes	no	somtimes
Perform the same tasks with either hand (i.e., writing, eating)	yes	no	somtimes
Seem to tire quickly, have poor posture, or need to prop his or her head while reading or writing at a desk	yes	no	somtimes
Find gym class or sports to be a particular difficult or frustrating experience	yes	no	somtimes
Tend to clutter work areas excessively	yes	no	somtimes
Have excessive difficult switching from active to quiet activities (i.e., playground to seatwork)	yes	no	somtimes

2. Social Adjustment:

Compared with others of the same age, does the client:

Social Skills	Yes	No	Sometimes	Remarks
Find it hard to make friends among his peers	yes	no	somtimes
Prefer the company of adults to that of peers	yes	no	somtimes
Prefer to play with younger children rather than peers	yes	no	somtimes
Prefer to play alone	yes	no	somtimes
Frequently get discouraged easily, or express feelings of failure or frustration	yes	no	somtimes
Seem to have less fun when playing	yes	no	somtimes
Frequently express feelings of anger or frustration by hitting or kicking rather than with word	yes	no	somtimes
Frequently throw temper tantrums	yes	no	somtimes
Have difficulty calming himself/herself when upset	yes	no	somtimes
Have difficulty following instructions	yes	no	somtimes
Dislike changes in routines	yes	no	somtimes

Please list any other family members or caregivers (parent, sibling, grandparent, nanny) who routinely look after the client. Include ages of any siblings.


3.Sleep Habits:

What position does the child sleep in (tummy, back, side)?


Describe client's sleep location (e.g. crib, bed, co-sleep).


What time is bedtime?


How well does the client transition to bedtime?


How many hours a night does the client sleep? Any naps?


Any difficulties with sleeping?

Thank you for taking the time to fill out this questionnaire.

This information will greatly assist the therapist working with the client in meeting his/her needs. Please feel free to make additional comments in the space below.