Al Shams Centre مركز الشمس

Occupational Therapy Parent

Directions

Your child has been referred to Al Shams Centre for an assessment. We would appreciate your assistance in gaining a full understanding of your child’s needs by answering the questions below.The information provided is important in determining the most appropriate assessment and intervention for your child. If you are unsure please indicate in the space provided or by stating. Once completed, please return or email to Al Shams Centre at the address given below.Thank you for your assistance.

General Information
Name of Child: / Today’s Date:
Date of Birth: / Person completing form:
Address: / Relationship to Child:
School: / Mother’s Name:
Grade: / Father’s Name:
Teacher’s Name: / Languages: Primary
Religion: / Languages: Secondary
How did you find out about our services?
Reason why you are seeking help?
Background Information
Medical Information:
Doctor/paediatrician currently involved:
Medical diagnosis (if any):
Medical history: (colic, allergies, eczema, ear infections, asthma, sinus, seizures)
Illnesses:
Current medication:
Hearing: (concerns/tests/results)
Vision: (concerns/tests/results)
Previous Assessments/Interventions:
psychological, educational, speech, physio, OT, neurology
Prenatal and Birth History:
Was this the first pregnancy?
How many before?
During this pregnancy, did the mother experience any unusual illness, condition, or accident, such as German measles, Rh incompatibility, false labour, etc? If so, please describe
List medications taken by mother during pregnancy
Length of Pregnancy
Was your child born premature / Late, how many weeks?
Duration of Labour / Birth weight
Were there any problems with the delivery, such as breech birth, Caesarean, etc.? If so, please describe
Conditions immediately following birth:
Did the infant have trouble starting to breathe? Was infant blue? Jaundiced? Seizures? Scars or bruises? Apgar rating
Did infant have sucking or swallowing difficulty?
Feeding problems? Was birth weight regained quickly?
Other problems?
Does your child suffer from frequent ear, nose, throat or chest infections?
Is there a history of learning difficulties within your family?
Personal and Family History
Was your child was adopted or in foster care?
Other children in the family:
Names and ages:
Other family members: Grandparents, Uncles and/or aunts?
How does your child get along with other children in the family?
Friends/playmates?
Does your child have a Nanny?
Educational History
List nursery and/or schools he/she previously attended:
At what age did the child start school? Where?
What are the child's usual grades?
Have teachers noted any areas of difficulty?
Please describe:
Does your child receive additional support in the school? SEN, Shadow teacher?
How does he/she get along with others at school?
Does your child participate in extracurricular activities? Please list:
Developmental History
Milestones: At what age in months were your child when he/she:
Lift head while on stomach / Rolled over / Sat alone / Crawled correctly
Walked / Climbed stairs
Current Development
The rating scale is graded in response to a child’s skill, ability or behaviour in the following areas. If unsure or not observed, please indicate in the box provided:
Mealtimes: / Never / Sometimes / Usually / Always / Unsure
Feed herself appropriately for age
Good appetite/eats all food groups
Messy eater
Food preferences determined by texture, taste, smell
Dressing: / Never / Sometimes / Usually / Always / Unsure
Independent for age
‘Helps’ to dress by lifting arms, pull shirt down, etc.
Can do up buttons
Can put on socks
Can put on shoes
Can tie laces
Needs prompts to keep on task
Personal Hygiene: / Never / Sometimes / Usually / Always / Unsure
Wash face and hands independently
Bath, shower independently
Brush teeth
Comb hair
Use toilet
Sleep: / Never / Sometimes / Usually / Always / Unsure
Average hours per night:
Difficulty falling asleep
Wakes up during the night
Dreams/ Nightmares
Bedwetting/ soiling
Awakes well and is more energetic in the mornings
Complains about being tired
Needs daytime sleep
Gross Motor Skills
Question / Yes / No / Comments
Please describe if your child has difficulty in any of the following areas:
  • Balancing
  • Running
  • Jumping
  • Hopping
  • Skipping
  • Learning to ride a bike / swim
  • Catching / throwing a ball

Does your child:
  • Have poor sitting posture?
  • Appear awkward in movements?
  • Frequently bump into things or other people?
  • Confuse right and left body sides?
  • Tire easily?

Fine Motor Skills
Question / Yes / No / Comments
Please describe if your child has difficulties in any of the following areas:
  • Holding a pen / pencil
  • Drawing / colouring within boundaries
  • Hand ache
  • Handwriting
  • Presenting / organising his/her work
  • Writing with appropriate speed
  • Using Scissors / ruler
  • Choosing a dominant hand
  • Breaking toys/ equipment frequently
  • Completing word searches / mazes/ dot-to-dots

Sensory Processing
Question / Yes / No / Comments
Please describe if your child has any difficulties in any of the following areas:
  • Covers ears for loud noises
  • Overly distracted by noise in the room
  • Makes sounds and noises to him/herself
  • Enjoys looking at spinning toys
  • Seeks movement / on the go/ fidgets
  • Takes excessive movement risks
  • Becomes care sick
  • Seeks to touch different textures
  • Is sensitive to fabrics
  • Over reacts to touch
  • Avoid getting hands wet or messy
  • Chews on non-food items
  • Over or under reacts to pain / temperature
  • Smells or sniffs items
  • Prefers quiet activities

General Skills
Question / Yes / No / Comments
Please describe if your child has difficulties in any of the following areas
  • Finding toys in a cupboard/ bag
  • Getting lost in familiar places
  • Concentration / attention
  • Remembering instructions
  • Peer interactions / play skills
  • Language / Pronunciation / Understanding
  • Giving / maintaining eye contact
  • Attending parties / family events
  • Going to supermarkets or standing in line
  • Being too impulsive / too passive

Speech and Hearing
Question / Yes / No / Comments
Did your child babble or coo?
Did it increase after 6 months?
Could you distinguish various types of cries?
When did you child :
Speak first words? ______
Put two words together? ______
Speak in short sentences? ______
Do you think your child speaks as well as other children of the same age?
How does your child let you know what he/she wants?
Please check any items that apply to your child:
No speech present / Rarely speaks / Lack of response when spoken to
Speaks too fast / Keeps mouth open / Often seems to ignore when being spoken to
Speaks too softly / Drools / Can’t begin speaking easily or stutters
Speaks too loud / Tongue thrust / Speech is not understandable
Voice is hoarse / Talks too much / Talks but can’t get to the point
Voice is nasal / Cannot find the words / Difficulty chewing or swallowing
High pitch / Yells / Complains of ear pain
Other:
Play and Behaviour
Gross motor play: / Never / Sometimes / Usually / Always / Unsure
Appears coordinated for age
Clearly uses L or R hand/foot (please circle)
Rides bike/scooter/tricycle/ bike with stabilisers (circle)
Plays with balls – throws, kicks/catches/hits (circle)
Seems weaker/stronger than others (circle)
Physically tires quicker than others
Plays appropriately for his/her age
Plays on the computer/ I-Pad
How long
How long can he/she attend to TV or listen to a story
Does your child have difficulty sticking to one activity for 2-3 minutes?
15-20 minutes?
Does your child:
Have difficulty switching activities?
Have rituals or need to do the same things the same way?
Have tantrums?
Hit/bite?
Describe any other behaviour problems you have with your child:
What disciplinary methods do you use?
Does your child have many friends?
Does he/she prefer to play with older children? ______
Younger children? ______
Alone? ______
Does your child have unusual fears?
Preoccupations?
Favourite Indoor play?
Favourite Outdoor play?
Please check any terms that apply to your child:
Shy / Friendly / Cooperative / Creative
Nervous / Overly talkative / Jealous / Thumb sucker
Nail biter / Destructive / Angry / Aggressive
Ritualistic / Rocks / Head banger / Poor tolerance for change
Bites / Fidgety / Affectionate / Short attention span
Lazy / Overly active / Absent minded / Lacks self confidence
Cuddler / Picky eater / Poor appetite / Rarely shows emotion
Daydreams / Avoids eye contact / Looks through you / Good self esteem
In your opinion, what are your child’s strengths? Please describe other strengths and weaknesses of your child:
What would you most like changed / hope to gain from the assessment:
Further comments:

Please attach any further comments or relevant reports.

Child Development Questionnaire- Confidential

P.O. Box 2710, Al Riqqa street 29, Al Jazzat area, Sharjah; Tel: 065667339; e-mail:

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