|
| |
Parent's Occupational Therapy Intake
Screening Form for All School
Age Children
Parents: Please
Complete All Three Sections
Copyright 2004 by Simoneon Pediatric Development Center. All rights
reserved.
Click
here for a PDF version of this intake form
Section
One: General Information
Child's
Full Name: ____________________________________________
Parent's Full
Name(s): _________________________________________
Child's Birth date: ___________________ Today's Date:
_____________
Mailing Address: _____________________________________________
Home Phone: __________________ Other
Phone(s): _______________
Fax: __________________________ Email(s): ____________________
Section Two
Section Three
Please circle all items of
past and current concerns for your
child:
Health:
-
Frequent ear infections or sinus infections.
-
Catches colds and/or the flu frequently.
-
Diagnosed medical condition, which restricts
physical activity (i.e. heart problem, asthma).
-
Has a confirmed diagnosis, which may be
related to delays in development (i.e. seizure disorder, breathing or heart
problem, autism, Down Syndrome, cerebral palsy or other). Please
specify__________________________________________
-
Has a chronic medical condition (i.e. asthma,
digestive disorder, heart problems, etc.) Please specify
__________________________________________
-
Has a communicable disease (Herpes, HIV, TB
etc).
-
Requires such interventions as suctioning or
special positioning.
-
Requires medication(s). If so, for what
reason?____________________________
-
Has a feeding problem.
-
Has a nasal gastric or gastric feeding tube.
-
Has frequent diarrhea or constipation.
-
Has food allergies. If so,
what?__________________________________________
-
Has environmental allergies. If so,
what?__________________________________
-
Has medication allergies. If so,
what?____________________________________
-
Wears hearing aid(s) .
-
Wears corrective lenses. If so, what
correction?____________________________
-
Requires splints, bracing or other appliances
for improving function.
Sensory
Organization/Regulation:
-
Behavior deteriorates when the schedule
changes.
-
Sleep patterns are irregular.
-
Withdraws from social situations.
-
Avoids eye contact with others.
Audi tory:
-
Does not seem to enjoy being sung to or read
to.
Ignores or takes a long time to respond
when parent talking with him/her.
-
Startles easily.
-
Has difficulty self-calming.
-
Cries easily with reason not always apparent
-
Has frequent meltdowns.
-
Sensitive to sounds, which typically don't
upset others his/her age.
-
Frequently covers ears to reduce hearing
certain sounds
-
Tries to escape from noisy environments.
Tactile:
-
Resists being touched or cuddled.
-
Becomes irritable with weather changes.
-
Becomes excessively irritable with wet diaper
or wet clothing.
-
Becomes agitated with hair washing.
-
Resists tooth brushing.
-
Avoids certain food textures or temperatures.
-
Refuses all but a few food choices.
-
Refuses to drink from a cup.
-
Desires very spicy foods.
-
Seems unaware of liquid or food left on
his/her lips.
-
Avoids contact or becomes upset with messy
activities or when in contact with cold, rough, sticky, gooey, dirty or
sandy surfaces.
-
Rarely cries when injured.
Proprioceptive:
-
Seems to never get
enough movement. He/she is always on the go!
-
Wants excessive amounts of rough and tumble
play; likes bumping into objects or seeks vibration by leaning on washing
machine, dryer, stereo speakers etc.
Vestibular:
-
Fusses or cries when tipped backward for
diaper changes, hair washing in the bathtub or with play.
-
Dislikes rocking, swinging, spinning,
bouncing and/or being upside down.
Visual:
-
Is disturbed by bright lights or
brightly colored toys.
-
Excessive interest in bright lights or
brightly colored objects.
-
Seeks out objects which move or spin (i.e.
ceiling fans)
Cognition:
-
Considering his/her age, this child is slow
to respond (i.e. smile, reach, imitate gestures and actions) to my
interactions with him/her.
-
Not making good eye contact with parent or is
not as emotionally responsive as other children this age.
-
May not search or attempt to find parent
(with eyes or body movement) when parent calls him/her from a distance.
-
Relative to his/her age, has little interest
or is unable to play with toys purposefully or plays with only a few select
toys.
-
Relative to his/her age, has difficulty
understanding cause and effect relationships (As infant, does not seem to
understand that differing cries bring different things (i.e. food,
diaper change, attention. Beginning as a toddler, doesn't seem to
understand that different actions have different outcomes).
-
As a toddler is or was demonstrating
difficulty matching, sorting, (visual
discrimination skills) or having problems with spatial relationships.
-
Problems with memory (visual or auditory)
relative to his/her age.
-
Difficulty problem solving.
-
Relative to his/her age, difficulty learning
or retaining previously taught concepts.
Speech and Language:
-
Does not watch
eyes, mouth and/or body language of parent when parent talks to him/her.
-
Does not seem to understand facial
expressions from others.
-
Does not typically respond to his/her own
name.
-
Does not seem interested when parent talks to
him/her.
-
Does not seem interested in
interacting/communicating with others.
-
Does not seem to enjoy music.
-
Child's cues to have needs met are difficult
for most to interpret.
-
Does not seem to use his/her voice to get
attention and/or have needs met.
-
Suspect child may have a hearing loss, but
this has not been not diagnosed.
-
Relative to age, child may not respond to
verbal requests unless accompanied by physical gestures or demonstration.
-
As a toddler does not or did not show an
understanding of familiar words by demonstrating appropriate behavior or
making a gesture.
-
As a toddler, does not or did not look at
frequently used objects (i.e., bottle, spoon, cup, shoes, ball, doll etc.)
when named.
-
Beginning as a toddler does not or did not
seem to be interested in toddler books and simple stories.
-
As an infant is not making many sounds, as a
toddler or older child is not saying enough words relative to his/her age.
-
As an infant/toddler or older child, is not
vocally or with his/her face expressing a variety of emotions.
Gross Motor:
-
As an infant requires or required more
support for sitting, standing or walking than other children this age.
(seems or seemed to require use of external supports or his/her own hands
for support).
-
Motor milestones were later than expected for
age or certain milestones were missing (i.e. rolling, crawling).
-
Moves with difficulty or appears awkward with
movement.
-
Does not seem as strong as other children
his/her age.
-
Seems to fatigue quicker than other children
his/her age.
-
Child's body is somewhat rigid or stiff.
-
One side of child's body is less coordinated
than the other side.
-
Has difficulty figuring out how to move
his/her body, getting in and out of positions and moving around the
environment.
-
Appears less coordinated and appears to have
less motor skills than other children his/her age.
-
Concerned for this child's safety relative to
his/her delayed balance responses.
-
Child seems to have a poor sense of his body
and may run into or fall over objects in the environment.
-
Falls more frequently than other children
this age.
-
Balance responses are in but appear awkward
or exaggerated.
Fine Motor:
-
Has difficulty following a moving object with
his/her eyes.
-
Excessive mouthing of objects or fingers
beyond expected age.
-
Has difficulty keeping his/her hands open
(any age).
-
Has difficulty holding objects (in a
coordinated way), relative to other children this age.
-
Does not sufficiently explore his/her body or
his environment with his/her hands and/or body.
-
Avoids weight bearing through his/her hands.
-
Has a limited repertoire of hand skills
relative to his/her age.
-
Positions hands or holds/manipulates objects
awkwardly.
-
Has difficulty playing with age appropriate
toys, using his/her hands.
-
Uses one hand much better than the other, or
avoids using one hand.
-
Has difficulty using both hands at the same
time.
-
As an older infant or toddler lacks or lacked
typical interest in filling/emptying containers, scribbling, stacking
rings/blocks, pulling/placing pegs, poking index fingers into things,
doing simple knob puzzles. As older child has little interest in age
appropriate toys or age appropriate interaction with those toys.
-
When a toddler and possibly not long
ago (if an older child) demonstrated little interest in using writing
implements, eating utensils or manipulating objects.
Social-Emotional:
-
Does not relax when held or given a back rub.
-
Does not calm with parent voice.
-
Does not demonstrate anticipation.
-
Seems indifferent to the presence or
attention of familiar others much of the time.
-
Does not respond to facial expressions of
familiar others (present after 6 months).
-
Resists or does not appear to enjoy social
play with familiar others (happens between 6 -10 months).
-
Does not show anxiety when separated from
parent (happens at 6 -10 months) .
Does not seem to discriminate between
familiar and non-familiar others (starts around 12 -18 months).
Demonstrates little interest in independence
(starts around 12 -15 months).
Has no need to be the center of attention
(starts between 12 -18 months).
Does not initiate or respond with hugs and
kisses to parents (between 14 -16 months).
Does not laugh at incongruities (i.e. a dog
wearing a hat, a fork being held between a parent's toes, a sock put on a
parent's head). This behavior starts between 12 - 18 months.
Minimal or absent varied range of affection
displays (starts between 18 - 24 months).
Does not display a wide range of emotions:
joy, anger, guilt, sympathy, modesty (starts between 18 - 24 months).
Does not interact with peers using gestures
(starts between 18 - 24 months).
Does not engage in parallel play (starts
between 18 - 24 months).
Does not engage in interactive play, if older
than 24 months.
Does not attempt to comfort others in
distress by crying and/or patting the person (starts between 22 -24 months).
Self-Help:
-
Cannot or did not sleep 4 - 10 hour intervals
at night (between 1 - 3 months).
-
Cannot or did not sleep 10 - 12 hours with 1
night awakening (between 4 - 8 months).
-
Cannot sleep or did not sleep 10 - 12 hours
with no night awakening (begins
between 13 - 18 months).
-
Cannot or did not bring hand to mouth in both
back and tummy positions (begins between 2-4 months).
-
Has or had poor coordination of sucking,
swallowing and breathing. (begins
between 1 - 5 months).
-
Has or had difficulty moving tongue around to
manage solid foods (begins between 5 - 8 months).
-
Cannot or did not hold own bottle (begins
between 5 - 9 months).
-
Cannot or did not finger feed self ( begins
between 9 - 12 months).
-
Does not cooperate with dressing by extending
arm or leg (begins 10 - 12 months).
-
As an infant/ toddler cannot or could not
bring spoon to mouth, with spilling expected (begins between 12 - 15 months).
-
Does not or did not hold cup and drink from
cup, with some spilling expected (begins between 12 -18 months).
-
Has or had not established regular
bowel/bladder control pattern (begins between 12 -18 months).
-
Does or did not indicate discomfort for wet
or soiled diaper (begins between 12 -18 months).
-
Does not or did not demonstrate interest in
imitating adult doing any house
chores (begins between 12 -18 months).
-
Cannot or did not scoop food with utensil to
self-feed, some spilling expected
(begins between 15 - 24 months).
-
Cannot or could not unzip large zipper
(begins between 18 - 21 months).
-
Does not or did not distinguish between
inedible and food items (begins between 18 - 23 months).
-
Does or did not explore cabinets and drawers
(begins 18 - 24 months).
-
Cannot or could not remove shoes with laces
undone (begins between 18 - 24 months).
-
Cannot or could not wash and dry hands
partially (begins between 19 - 24 months).
-
Does not or did not help with simple
household tasks (begins between 21 - 23 months).
-
Does not or did not handle fragile items
carefully (begins between 24 - 26 months).
Part Two for School Age Child
Please circle all items of
past and current concerns for your
school age child:
Gross Motor Skills and
Postural Control:
1. Difficulty performing age appropriate
playground or outdoor skills (negotiating climbing
structures, swinging from overhead structure - bar to bar, jumping rope,
riding a bike,
roller skating, team sports etc.) or hesitates to do so
2. Games involving ball handling skills are
difficult
3. Using playground equipment safely is
difficult
5. Fears and/or resists heights or balance
challenging activities, (use of playground
equipment, descending stairs, use of escalator)
6. Fears fast moving carnival rides
7. Gets nauseated easily with car trips and
carnival rides
8. Difficulty performing unfamiliar or
unpracticed motor tasks or child is resistant to do so
9. Difficulty with sequential motor tasks
10. Difficulty with rhythmical motor tasks.
11. Seems to need constant motion, with
difficulty sustaining posture (remaining in chair
or standing without movement)
12. Tendency to lean and slouch on school
desk, dining table, chairs, other objects, on
people or prefer to lie on floor rather than remain erect.
13. Has difficulty coordinating body sides or
upper and lower body together (esp. noticed
with rhythmical or sequential motor activities)
14. Confuses right and left body sides
Fine Motor Issues
1. Difficulty with drawing, coloring,
cutting, copying or avoids these activities
2. Inappropriate pencil and utensil grip for
age
3. Holds pencil too loosly or too firmly
4. Resists or has difficulty with clothing
fasteners and/or shoe tying
5. Uses both hands about the same amount of
time (hand dominance does not appear
established)
6. Difficulty with changing eye focus from
near to far and back (copying from a paper at the
desk or whiteboard on the wall)
7. Problems with eye convergence (for near
point work needed for reading, writing and
making close proximity sustained eye contact)
8. Difficulty eye tracking moving objects
(i.e. balls for playground activities) or tracking
words across a printed page (without skipping words, letters or saying the
wrong word)
9. Difficulty moving the eyes without moving
the head
10. Continues to be a sloppy eater (eating
with mouth open, inappropriate chewing patterns,
poor tongue/lip control or swallowing patterns)
11. Still has few food choices, not because
of defensiveness to textures or dislike of taste
but rather due to difficulty with use of tongue/lips for managing food
outside the mouth
(licking ice cream cone) moving food around in mouth, chewing the food or
safely
swallowing those consistencies
12. Has better oral-motor control with spicy,
hard and/or textured foods
13. Has better swallow control with pureed or
pudding consistency foods
Visual Perception:
1. Difficulty with learning colors, shapes,
sizes
2. Unfamiliar puzzles are quite challenging
(with much trial and error placement of pieces)
3. Avoids or dislikes visual perception tasks
(puzzles, writing, coloring, scissor use, writing
letter/numbers with expected form/size and within expected lines/spaces)
4. Reversals of letters and/or numbers after
1st grade
5. Gets lost in familiar places
6. Difficulty finding objects in backpack,
desk dresser drawer or room
Touch:
1. Still seems to have difficulty refraining
from touching things and possibly people
2. Does not seem to notice when bumped or
injured (unless there is blood
3. Prefers eating spicy foods and/or very
textured foods over bland and soft foods
4. Seems overly sensitive to being touched,
esp. light touch (may avoid physical activities
involving others for this reason, not for lack of physical skill)
5. Intolerance to splashing of water or
shower
6. Excessively ticklish
7. Bothered by clothing (tags, textures, fit
of clothing, certain fabrics)
8. More sensitive to pain than others
9. Problems with others being too close to
him/her (seating arrangement at school,
standing in line position at the dinner table, being in a crowd)
10. Still avoids activities involving messy
or dirty substances (using glue, finger paints, sand
or mud etc.)
Olphactory (Smell):
1. Seems overly sensitive to odors, which
others seem not to notice or are not bothered by.
2. Smells everything, even non food items
3. Likes foul smelling odors and may seek
them out
4. May eat or drink foods/drinks which are no
longer fresh (does not seem to notice foul odor
or taste difference
5. Likes certain fragrances/smells, which
seem to be calming or pleasurable
Auditory/Language:
1. Child is difficult to understand when
speaks, relative to his/her age expectations
2. Difficulty understanding what is said to
him/her and may misinterpret information
3. Trouble following 2-3 step commands
(unless visual supports or demonstration given)
4. Inattention to others speaking to him/her
5. Need to repeat spoken information over and
over
6. Poor short-term auditory memory
7. Easily distracted by sounds, which go
unnoticed by others
8. Difficulty understanding what was spoken
to him/her in noisy backgrounds (restaurant,
classroom, shopping mall, a party)
Social-Emotional Issues:
1. Is still not accepting changes in routine
easily (prefers sameness) and transitions poorly
2. Becomes easily frustrated
3. Is difficult to comfort, when upset
3. Has strong feelings of anger or rage
4. Has panic or anxiety attacks
5. Has lack of self-confidence
6. Has difficulty getting along with peers
and maintaining relationships
7. Tendency to be impulsive and not attending
to consequences or potential safety issues
8. Overall, typically does better one-on-one
than in a group situation
9. Prefers to be alone, rather than with
others.
10. Has few or no friends.
11. Seldom gets asked to parties or playdates.
12. Still having outbursts, temper tantrums
and melt downs beyond age expectations and/or
for prolonged duration of time.
13. Struggles with making needs known in
appropriate manner.
14. Withdraws from social situations and/or
playground activities, playing by him/herself on
the periphery of peers activities
15. Still avoids eye contact, even when
interacting or attempting interaction with others
16. Has a limited range of emotion.
17. Does not demonstrate ability to read
others emotions, esp. non-verbal expressions of
emotion (body language).
18. Does not seem aware of others emotional
needs.
19. Does not seem able to halt inappropriate
behavior if disturbing to others (even if
brought to the child's attention).
return to top of Part 2 for
School Age Children
return to top of page
|
