Intake Child

YOUR CHILD'S FAMILY HISTORY:

Name Education Workplace Work Number Age
Mother
Father

BROTHERS AND SISTERS

Name Age Sex Occupation Highest Grade Achieved

EDUCATION INFORMATION: (Check highest level)

Was your child ever enrolled in special education classes?

PHYSICAL HEALTH INFORMATION:


  Date Reason Results
Last
Physical

MM/DD/YY
Last
Doctor
Visit

MM/DD/YY
Last
Dental
Visit

MM/DD/YY
Have you noticed any recent changes in your child's:
Sleeping Patterns Behaviour
Eating Patterns Energy
Physical Activity Weight
Increased Tension Disposition
MEDICAL INFORMATION: Past and Present (Please Check any)
  No Past Present
Allergies
Asthma
Ulcer
Chronic Stomach
Heart Disease
Seizure/Epilepsy
Fainting/Dizzy
Hallucinations
High/Low Blood Pressure
High/Low Blood Sugar
Thyroid Problems
Liver Disease
Vision Problems
Hearing Problems
Broken Bones
Major Injuries
OB/GYN Problems
Diabetes
Communicable Diseases
Nutritional Problems
Other problems (specify): 
  Past   Present

Current Medication and Drug Use: (Include all drugs)

Name of Drug Prescribed ? Dosage Frequency

Previous medication and/or drug usages (prescription and non-prescription)

Name of Drug Dosage Reason of Stoppage
Has your child ever overdosed on a drug or medication?

RELATIONSHIPS:

Please briefly describe how you get along with:

PRIOR COUNSELLING/TREATMENT INFORMATION:

Have you ever received prior counselling, drug, or psychiatric services?

ALCOHOL/SUBSTANCE USE:

Does your child use alcohol regularly?
yrs. old.
yrs. old.
Do you use other substances?
Has drinking or substance use ever caused problems for your child?
Have members of your child's family experienced difficulty with alcohol or substance abuse?

CHILD-DEVELOPMENTAL PROFILE

EARLY DEVELOPMENTAL HISTORY

  1. The age of the natural father when the child was born?   
  2. The age of the natural mother when the child was born?   
  3. What was the mother's attitude while pregnant with the child?   
  4. Did the mother receive medical care while pregnant?   
  5. Describe any complications with the mother while pregnant.   
  6. Describe any problems with the birth of the child.   
  7. What was the child's approximate birth weight when born?   
  8. Who cared for the child before the age of two?   
  9. Describe the child's mood before the age of two.   
  10. From birth to the age of two how was the child's development of physical skills?
  11. At what age did the child walk?   
  12. At what age did the child talk?   
  13. At what age was the child toilet trained?   
  14. Describe any problems with the toilet training.   
  15. Who was the caregiver from the age of two to five?
  16. Describe any problems in the child's motor development between the age of two and five. (i.e.. running, jumping, throwing, etc.)
  17. Describe the child's language development from age two to five. (i.e.. talking in sentences, vocabulary, etc.)
  18. What was the social development of the child between the age of two to five? (i.e.. how did they get along with others)
  19. Describe the child's mental development from age two to five   
  20. Describe the child's temperament for the age of two to five.   

KINDERGARTEN

  1. Describe any difficulties when starting kindergarten.   
  2. At what age did he/she start kindergarten?   
  3. Did the child enjoy kindergarten?   
  4. How did the child get along with other children?   
  5. Describe the child's academic performance in kindergarten.

GRADE ONE

  1. At what age did he/she start?   
  2. Describe any problems.   
  3. How did the child get along with the other children?   
  4. Describe the child's academic performance.   

OTHER GRADES

  1. Describe the child's school experiences since the first grade.   
  2. What are the child's current subject strengths in school?   
  3. What are the child's current subject weaknesses in school?   
  4. Describe the child's current skill strengths. (i.e.. spelling, concentration, organization, test preparation, handwriting, understanding concepts, reading, intelligence, behaving, etc.)
  5. Describe the child's current skill weaknesses. (i.e.. as above)
  6. Does the child currently complete homework assignments on time? 
  7. Is there any additional academic support to the child presently? 
  8. Does the child skip school or class? 
  9. How often is the child excused from school? (for illness, etc) 
  10. Are there currently any behaviour problems in the classroom? 
  11. Explain any problems with attention and concentration that the child is now experiencing.

ATTENTION DEFICIT DISORDER (A.D.D.) SEVERITY SCALE

Choose the number that best describes your child's attention or behaviour difficulties at school.
1.  Often fidgets or squirms in seat.
2.  Has difficulty remaining seated.
3.  Is easily distracted.
4.  Difficulty waiting for his/her turn.
5.  Often blurts out answers to questions.
6.  Has difficulty following instructions.
7.  Has difficulty keeping attention to task.
8.  Often shifts from one uncompleted task to another.
9.  Often loses things needed for tasks.
10.  Often engages in physically dangerous activities
without considering consequences.

Choose the number that best describes your child's behaviour or attention difficulties at home.
1.  While playing with other children.
2.  Mealtimes.
3.  Getting dressed.
4.  When visitors are in your home.
5.  When you are visiting someone else.
6.  At church or Sunday school.
7.  In supermarkets, stores, restaurants, or other public places.
8.  When asked to do chores at home.
9.  While in the car.
10.  When asked to do school homework.

SUPPLEMENTAL INFORMATION

Is there anything else you consider important for us to know about yourself or your child?
Name

CONSENT TO ASSESSMENT AND TREATMENT

Please read and agree to the Standard of Care for Dr. Svec Rehabilitation Clinics.