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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Yes
No
NDIS number
NDIS funding
Plan-managed
Self-managed
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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Bottle fed
Breast fed
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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Snoring / mouth breathing
Bad breath
Head injury
Hyperactivity
Fractured limbs
Sleep challenges
Frequent day dreaming
Family history of allergies/intolerances
Refux
Eczema / skin rashes
Constipation / diarrhoea
Dark circles (purple shiners) under eyes
Bloating / gas / tummy discomfort
Asthma / respiratory problems
Other
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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Jacket
Pants
Shirt
Socks
Shoes
Button
Zipper
Tie shoes
What hand does your child use most frequently?
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Left
Right
Both
Tick if your child can do the following:
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Using scissors
Playing with small toys
Completing puzzles
Learning to swim
Riding a bike
Catching a ball
Kicking a ball
Dressing
Jumping
Using cutlery
Doing shoelaces
Holding a pencil
Writing / drawing
Pumping self on swing
Learning new motor skills
Food preparation/domestic skills
Checkbox
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Please tick any of the following your child has difficulties with:
Repetitive play or particular play or sensory preferences
Playing with other children
Playing at home
Participating in social activities (home or community)
Emotional regulation
Gross motor skills (playground or sports participation)
Mental health concerns
Sensory processing (e.g., sensitivities or sensory triggers)
Tick if your child displays the following
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Mostly quiet
Tired easily
Restless
Resistant to change
Talks contantly
Temper tantrums
Fearful
Poor attention
Seperation difficulties
Overly affectionate
Overly active
Impulsive
Stubborn
Sensitive
Fights frequently
Wets the bed
Frustrated easily
Perfectionist
Anxious
Immature
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:
A lot
Occasionally
Never
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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Using spoken language (vocabulary, using grammar, formulating sentences)
People understanding them
Unclear speech sound production
Understanding spoken language
Difficulty with particular words/sounds
Following directions
Reading and spelling
Has a hoarse, rough or strained-sounding voice
Reading comprehension
Stutters and gets stuck on words
Social communication
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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