Please enable JavaScript in your browser to complete this form.General Information - Step 1 of 5Name of Child *Date of BirthName of person filling questionnaireRelationship to childPreferred contact numberHome AddressEmail Address *Date questionnaire completedNote: Your impressions and opinions of your child’s abilities and comparative difficulties are very important in a complete assessment of your child. Please complete this questionnaire adding additional comments as necessary. This information will be treated as confidential at all times.NextBirth WeightPregnancyFull TermPremature(Born at) ___ weeksPlease describe any important illnesses, injuries or surgeriesCurrent medical diagnoses / conditions: (ADHD, Autism, CP etc)Current medication prescribedPreviousNextApproximate age at which your childRaised HeadRolledSat aloneCrawled on hands and kneesPulled to standStood aloneWalkedYour general impression of your child’s motor development: (tick as appropriate)Gross motor (running, jumping ball play)AdvancedNormalSlowFine motor (manipulation of objects with hands)AdvancedNormalSlowHandwriting & colouring skillsAdvancedNormalSlowFavourite indoor play?Favourite outdoor play?What are your child’s strengths?General behaviour (tick as appropriate)Does your child tire easily during activities?NeverSometimesUsuallyAlwaysUnsureDoes your child appear fearful of movement or heights? NeverSometimesUsuallyAlwaysUnsureIs your child impulsive?NeverSometimesUsuallyAlwaysUnsureIs your child easily upset by failure?NeverSometimesUsuallyAlwaysUnsureIs your child able to relate to peers? NeverSometimesUsuallyAlwaysUnsureIs your child negative about their own ability? NeverSometimesUsuallyAlwaysUnsureIs your child able to organise themselves and their belongings? NeverSometimesUsuallyAlwaysUnsureDoes your child have difficulty making friends?NeverSometimesUsuallyAlwaysUnsureDoes your child’s behaviour appear the same at home and school?NeverSometimesUsuallyAlwaysUnsureMealtime ability (tick as appropriate)Feed themselves (age appropriate)NeverSometimesUsuallyAlwaysUnsureGood appetite / eats all food groupsNeverSometimesUsuallyAlwaysUnsureMessy eaterNeverSometimesUsuallyAlwaysUnsureFood preferences determined by texture, taste, smellNeverSometimesUsuallyAlwaysUnsureDressing ability (tick as appropriate)Independent for ageNeverSometimesUsuallyAlwaysUnsureCan do up buttonsNeverSometimesUsuallyAlwaysUnsureCan put on socksNeverSometimesUsuallyAlwaysUnsureCan put on shoesNeverSometimesUsuallyAlwaysUnsureCan tie lacesNeverSometimesUsuallyAlwaysUnsureNeeds prompts to keep on taskNeverSometimesUsuallyAlwaysUnsureToilet / washing / personal hygiene (list difficulties – bath, shower, tooth brushing, toileting)Sensory & behaviour (tick as appropriate)Transitions smoothly between tasksNeverSometimesUsuallyAlwaysUnsureReacts appropriately to external noises/distractionsNeverSometimesUsuallyAlwaysUnsureReacts appropriately to different texturesNeverSometimesUsuallyAlwaysUnsureAppears to recognise objects by touch, manage small objects such as buttonsNeverSometimesUsuallyAlwaysUnsureAppears to sense where head and body are in space; can move easily through space without falling or running into people/objectsNeverSometimesUsuallyAlwaysUnsureMaintains postures (sitting or standing without slumping, moving around restlessly or bouncing)NeverSometimesUsuallyAlwaysUnsureDemonstrates self-controlNeverSometimesUsuallyAlwaysUnsureShows safety awareness as appropriate for their ageNeverSometimesUsuallyAlwaysUnsureUses personal space appropriately, does not intrude on space of othersNeverSometimesUsuallyAlwaysUnsureTakes turns during games and activitiesNeverSometimesUsuallyAlwaysUnsureDoes not get over-aroused; maintains controlled behaviourNeverSometimesUsuallyAlwaysUnsurePreviousNextAreas of concern: (tick as appropriate)Fine motorHandwriting Over/ under activeMotor weaknessMuscle tone Over sensitive / under responsiveFeedingEnduranceSensory processingDressingAttention / distractibilityToiletingPlay skillsPlease describe any of these concerns that have been checked and detail any other concerns you may have What would you like us to help you and your child with?Is your child currently receiving any therapy or involved in any special programs?What other evaluations, therapy or special programs has your child had in the past?PreviousNextAre there any other concerns or comments you feel would be helpful for us to understand your child better?PreviousMessageSubmit
Pediatric Occupational Therapy Services in London