Intake Questionnaire for School-aged Children

Intake Questionnaire for School Aged Children

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  • Pregnancy & Birth History

  • Please note issues during pregnancy with health of baby &/or mother such as pre-eclampsia, bleeding, trauma, poor growth etc. Also please note any complications around delivery such as cord around the neck, meconium, assisted delivery etc. Also note any post-birth issues such as resuscitation, ICU, assisted breathing, intubation etc.
  • Developmental History

  • Please note issues with walking, fine motor skills, gross motor skills, handwriting etc.
  • Please note any delays with starting to speak, making sentences, articulation, language comprehension etc.
  • Social Behaviour

  • Please note issues with getting along with others, making friends, keeping friends, poor eye contact, poor empathy, flat emotions, disinterest in others, monologues about interests even though others disinterested etc.
  • Medical Background

  • Please note if diagnosed with ADHD, autism spectrum disorder, oppositional defiant disorder, developmental delay, intellectual disability, genetic disorders etc. Please report name of clinician and year diagnosed. Please provide relevant reports.
  • Please note asthma, allergies, gut issues, constipation, lactose intolerance, head injury, ear infections, grommets, epilepsy, headaches, migraines, tic disorder etc. Please provide relevant reports.
  • Please note any issues with anxiety, depression, low self-esteem, anger, aggression, explosive behaviour, obsessive behaviour, issues with flexibility, problems with change etc. Please also note if they have seen a psychologist or mental health worker for treatment (who, when, how long).
  • Please note acuity issues, lazy/turned eye, tracking issues, depth perception, colour blindness etc. List any treatment such as glasses, vision therapy, eye operation etc.
  • Plea note any issues with hearing and any required treatment.
  • Please note any issues falling asleep (how long), issues with waking in the night, energy levels or fatigue upon waking, nightmares, teeth grinding, bedwetting etc.
  • Family History

  • Please list any relevant family history such as ADHD, ASD, learning problems, emotional disorders or psychiatric disorders (suspected or diagnosed).
  • Educational Background

  • Goals of assessment