Parent / Carer Questionnaire / Intake Form - Steps to Strides Occupational Therapy

This questionnaire has been developed to get a better understanding of your child. Please answer as many of the questions as possible.
* Denotes compulsory field.

If you prefer, you can download this form as a PDF here »

CHILD'S PARTICULARS

REASON FOR REFERRAL

ADDITIONAL SERVICES INVOLVED

Please list other professionals your child has been involved with. Please supply brief details of your goals, when your child was seen by this professional and their contact details.

Therapist

Speech Therapist

Psychologist

Paediatrician

Occupational Therapist

Dietician

Gastroenterologist

Optometrist

Tutor

Other

* If your child has seen another professional, please provide copies of their report(s) via the file upload section at the end of this form.

FAMILY DETAILS

Parent 1

Parent 2

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Is there any family history of ADHD, ASD, learning or co-ordination problems (list below)

MEDICAL HISTORY

Please give details regarding the following:

Has the following been tested?

Vision
YesNo

Hearing
YesNo

PREGNANCY AND BIRTH HISTORY

DEVELOPMENTAL MILESTONES

At what age (approximately) did your child:

SCHOOL

MOTOR SKILLS

Catching a Ball

Throwing a Ball

Kicking a Ball

Jumping

Balancing

Hopping

Climbing

Riding a Bicycle

Swimming

UNDERLYING ABILITIES

Coordination

Body Awareness - avoids bumping into objects and others

Muscle Tone / Postural Control

Energy levels at the end of the day

Dominant hand

Ability to sit still

FINE MOTOR + VISUAL PROCESSING SKILLS

Drawing

Handwriting - formation, size, spaces

Handwriting speed

Cutting out

Colouring in

Pencil grip

Finding place on page (e.g. reading)

WRITTEN EXPRESSION

Capital letter use

Use of punctuation

Generating ideas for writing

Organisation of ideas (e.g. sentence structure, within text type)

Write age appropriate quantity in given timeframe

ATTENTION, CONCENTRATION + EXECUTIVE FUNCTIONING

Listening

Sitting still

Task perseverence

Concentration

Gets started + organised for task

Impulse control

Remembering goal of a task

PERSONAL CARE

Dress / undress

Toileting

Puts on clothes with correct orientation

Clothes fastening (e.g. zips, buttons)

Using a fork and knife

Tidiness when eating

Brushing teeth

Showering self

Managing period (period undies, pads, tampons, etc) - where applicable

LANGUAGE

Remembering a message

Follow 1 step instructions

Follows complex instructions

SOCIAL / EMOTIONAL SKILLS

Joining in games

General behaviour

Makes and keeps friends

Coping with changes, new situations

Eye contact

Problem solving

Separating from parents

Understands basic emotions (happy, sad, angry)

Understands complex emotions (worried, embarrassed, annoyed)

Expresses emotions appropriately

SENSORY

Seems to be in a constant state of movement

Frequently bumps into things / appears clumsy

Reacts strongly to being bumped or touched

Avoids messy play and doesn't like to get hands dirty

Prefers or seeks out rough play

Loses place when reading or copying from the board

Reacts negatively to loud noises

Reacts strongly to smells

Fussy eater, gags on food

High pain threshold

THERAPY GOALS

Please list your goals for your child's therapy. Be as specific as possible.

FILE UPLOAD (Optional)

Max file size: 5Mb. Acceptable file types: PDF, DOC, ODT, PNG, JPG.

Note: If you encounter problems uploading files via this form, please email them directly to bec@stepstostrides.com.au.

This questionnaire has been developed to get a better understanding of your child. Please answer as many of the questions as possible. * Denotes compulsory field.