1. Patient Information
1. Reasons of Referral
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:
3. Developmental History
Please provide approximate ages or observations related to your child’s 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 |
Motor Learning & Regression
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 – 9 months | Grasps small items with thumb and index finger | ||||
| Finger feeds self | |||||
| 12 – 18 months | Holds a spoon | ||||
| Removes socks | |||||
| Notifies parent that diapers are soiled | |||||
| Cooperates with dressing | |||||
| 18 – 24 months | Holds and drinks from a cup with minimal spilling | ||||
| Able to load spoon and bring to mouth with moderate spilling | |||||
| 2 – 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 – 4 years | Independently dresses self, may need help with fasteners | ||||
| Independent with toilet control and notification | |||||
| 5 – 6 years | Independent with all dressing, including shoe tying |
5. Eating / Feeding
Please respond to the following regarding your child’s eating habits:
6. Current and Previous Behaviors
Please select Yes / No / Sometimes for each behavior. Add comments where applicable.
Infant Behavior (First 12 Months)
| 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
| Behavior | Yes | No | Sometimes |
|---|---|---|---|
| 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 |
7. Recommendation
Please provide your professional recommendation based on the consultation findings: