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+1. Patient Information
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+1. Reasons of Referral
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+Select only one option that best describes the primary reason for referral to OT.
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+2. Areas of Difficulty (Select up to 3)
+Please select up to 3 areas where your child has shown difficulties in the past 3 months, and provide brief details for each selected item:
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+Maximum 3 selections allowed.
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+3. Developmental History
+Please provide approximate ages or observations related to your childās developmental milestones:
+| Milestone | +Age / Notes | +
|---|---|
| Controlling head | +|
| Reaching for object | +|
| Rolling over both ways | +|
| Finger feeding | +|
| Sitting alone * | +|
| Pulling to stand | +|
| Creeping on all fours * | +|
| Drawing a circle | +|
| Eating with spoon | +|
| Cutting with scissors | +|
| Walking * | +|
| Drinking from a cup | +|
| Jumping | +|
| Hopping | +|
| Hopping on one foot | +|
| Riding a bike | +
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Motor Learning & Regression
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+If "No" is selected, please provide a brief explanation in the comment column.
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+4. Self-Help Skills
+Please indicate whether your child could perform the following tasks during the specified age range.
+| Age Range | +Task | +Yes | +No | +Comments | +|
|---|---|---|---|---|---|
| 8 ā 9 months | Grasps small items with thumb and index finger | ||||
| Finger feeds self | |||||
| 12 ā 18 months | Holds a spoon | ||||
| Removes socks | |||||
| Notifies parent that diapers are soiled | |||||
| Cooperates with dressing | |||||
| 18 ā 24 months | Holds and drinks from a cup with minimal spilling | ||||
| Able to load spoon and bring to mouth with moderate spilling | |||||
| 2 ā 3 years | Unzips zippers and unbuttons large buttons | ||||
| Requires assistance to manage pullover clothing | |||||
| Able to take off pants, coat, socks and shoes without fasteners | |||||
| Able to feed self with little to no spilling | |||||
| 3 ā 4 years | Independently dresses self, may need help with fasteners | ||||
| Independent with toilet control and notification | |||||
| 5 ā 6 years | Independent with all dressing, including shoe tying |
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+5. Eating / Feeding
+Please respond to the following regarding your childās eating habits:
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+6. Current and Previous Behaviors
+Please select Yes / No / Sometimes for each behavior. Add comments where applicable.
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+Infant Behavior (First 12 Months)
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+| Behavior | +Yes | +No | +Sometimes | +
|---|---|---|---|
| Cried a lot, fussy, irritable | |||
| Was good, non-demanding | |||
| Was alert | |||
| Was quiet | |||
| Was passive | |||
| Was active | |||
| Liked being held | |||
| Resisted being held | |||
| Was floppy when held | |||
| Was tense when held | |||
| Had good sleep patterns | |||
| Had irregular sleep patterns |
+Current Behavior
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+| Behavior | +Yes | +No | +Sometimes | +
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| Is mostly quiet | |||
| Is overly active | |||
| Tires easily | |||
| Talks constantly | |||
| Is impulsive | |||
| Is restless | |||
| Is stubborn | |||
| Is resistant to change | |||
| Fights frequently | |||
| Exhibits frequent temper tantrums | |||
| Is clumsy | |||
| Is frustrated easily |
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+7. Recommendation
+Please provide your professional recommendation based on the consultation findings:
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