Child's Name
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First Name
Last Name
Date of birth
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MM
DD
YYYY
Address
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Name of parent or guardian
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First Name
Last Name
Full name of who is completing this form on behalf of the client
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Does this child have current NDIS funding?
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NDIS number
NDIS funding
What are the main reasons you are engaging with an Occupational Therapist for your child?:
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Does your child have any formal diagnosis? If yes, please provide details:
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What would you like to achieve from Occupational Therapy sessions?
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Who referred you to Sunshine Speech and Allied Health services for Occupational Therapy?
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What are your child's interests and strengths?
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Please list any other details you feel relevant in supporting your child
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Describe any difficulties experienced during the pregnancy, including any unusual illnesses, conditions, or accidents:
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How many weeks was your child born and what weight was your child born?
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Describe any issues that occurred at birth, e.g., breech birth, emergency c-section, etc.
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Does your child have any siblings? If yes, please provide details (e.g., name, age, and any motor, visual, sensory, emotional, speech, language difficulties, etc.)
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Do any other close relatives have, or have a history of, difficulties with language, speech, reading, or spelling? If yes, please provide details:
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Do any other close relatives have, or have a history of, difficulties with visual, sensory, motor, and/or social-emotional skills? If yes, please provide details:
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Did your child have trouble starting to breathe?
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Type yes or no
If yes, please provide details:
As a baby, what was the main method of feeding?
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Did your child have any difficulties post-birth?
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Type yes or no
If yes, please provide details:
How often does your child get sick? (e.g., recurrent colds, ear infections, etc.)
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Does your child have any allergies?
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Has your child's hearing been tested?
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Has your child's vision been tested?
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Please list any surgeries or procedures your child has had to date
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Has your child previously engaged with any other allied health services before?
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Current Paediatrician/GP
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Has your child experienced any of the following?
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Did your child have any difficulties with the following? If yes, please provide details:
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- Feeding difficulties during infancy? (feeding, sucking, chewing, etc.)
- Any difficulties transitioning to baby foods?
- Difficult mealtime behaviors?
- Tolerating a variety of food textures and tastes?
- Ever choked on solid foods or coughs frequently on liquids?
Is your child able to use a:
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- Fork
- Spoon
- Open Cup
- Straw
- Finger feeds still
- Needs adult assistance
At what age did your child achieve the following milestones?:
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- Hold head up:
- Sit independently:
- Roll over:
- Crawl:
- Stand alone:
- Point:
- Walk independently:
- Run:
- Wave:
Please provide details for the following if relevant:
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- At what age did your child start to sleep through the night regularly?:
- Is your child toilet trained and if so what age were they toilet trained?:
- Does your child use a pacifier and/or suck their fingers/thumb?:
- Does your child continue to mouth objects?:
- Does he/she drool?:
- Does your child suck on hair/clothing/blanket, etc?:
- Does your child enjoy taking a bath?:
- Does your child resist tooth brushing?:
- Does your child appear overly sensitive to:
Loud noises, Bright lights, tags
Please tick if your child can independently put on:
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What hand does your child use most frequently?
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Tick if your child can do the following:
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Checkbox
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Please tick any of the following your child has difficulties with:
Tick if your child displays the following
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Languages spoken at home? (please specify main language):
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Did your child babble regularly as a child?:
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At what age did your child say their first words?:
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Does your child use two and three-word phrases to communicate?:
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Does your child talk:
Does your child consistently answer to his/her name?:
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Please tick any of the following your child experiences difficulties with:
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Does your child attend school, preschool, or early childhood education?:
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Does your child have any issues at school/preschool/childcare (e.g., socializing, challenging behaviors, reading, writing, or communication)?:
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Does your child receive special assistance or support at school/preschool/childcare?:
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