Thank you for the opportunity to evaluate your child. It is goal and mission at Kids Aboard Therapy to serve the children in our area, to help them be more independent and to improve their quality of life.

Please download the following forms, fill them out and send them back signed.

Then, fill in this questionnaire to get all the necessary information. When finished just click on the send button





Patient’s Info


Concerns

Has your child received a diagnosis?
YesNo


Please indicate name and address, only if your child has ever been seen by any of the following.







Developmental and Medical History


Is your child adopted?
YesNo


Please answer the following:
Breastfed
YesNo
Bottle Fed
YesNo
Specific Health Problems
YesNo
Thumb sucker/pacifier (to what age)
YesNo
Feeding problems
YesNo
Sleeping problems
YesNo
Colic or fussy baby
YesNo
Prefers certain positions
YesNo
Dislikes stomach
YesNo
Dislikes back
YesNo
Able to self sooth
YesNo
Mouthed toys
YesNo
Enjoys bouncing
YesNo
Calmed by car rides/infant swing
YesNo
Becomes upset by car rides/swing
YesNo
Toe walker (until what age)
YesNo
Feeding/swallowing difficulties
YesNo


Developmental Milestones

Please give approximate ages if remembered, or comment on anything unusual.


Visual and Auditory Development

Do you have any concerns about your child’s vision?
YesNo

Has he/she had a vision exam?
YesNo

Does your child wear glasses?
YesNo

Does your child do any of the following:

Close one eye or “wink”
YesNo

Trip/Fall frequently
YesNo

Tilt head to one side
YesNo

Have difficulty reading
YesNo

Complain of headaches
YesNo

Avoid eye contact
YesNo

Does your child do any of the following:

Cover his/her ears
YesNo

Confuses similar sounding words
YesNo

Not respond to call
YesNo

Gets easily distracted
YesNo

Avoid/ “fall apart” in noisy environments
YesNo


Speech and Language Development

Are the parents bilingual?
YesNo


Fine Motor Development

Please check all that apply to your child:
Holds a pencil/crayon well
YesNo

Able to manipulate objects
YesNo

Enjoys coloring
YesNo

Uses both hands together
YesNo

Able to snip with scissors
YesNo

Writes numbers and letters
YesNo

Able to cut paper
YesNo

Primarily scribbles
YesNo

Draws a picture
YesNo

Draws a person
YesNo

Pick up small objects
YesNo


Self Care/Daily Routine

Please select all that apply to your child
Eats with fingers
YesNo

Uses a spoon
YesNo

Uses a fork
YesNo

Drinks from open cup
YesNo

Drinks from Sippy cup
YesNo

Drinks from Bottle
YesNo

Manages


Social/Emotional

Does your child:

Enjoy hugs and kisses
YesNo

Enjoy interactive play with others
YesNo

Attempt to comfort others
YesNo

Display wide variety of emotions
YesNo

Prefer to play alone
YesNo

Have frequent tempers
YesNo

If is yes, how many a day?

Engage in eye contact during communication?
YesNoSometimes

Is he/she able to calm themselves?
YesNo


Sensory and Motor Development

Please check all that apply to your child:

My child is overly sensitive to sensory experiences more so than other children his/her age.
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My child does not react to sensory experiences as readily as other children his/her age.
AuditoryTactileVisualMovementTasteSmell

My child seeks out sensory experiences more so than other children his/her age.
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My child has difficulty differentiating sensory experiences (i.e. confuses sounds, cannot find objects in a drawer or bag without looking, bumps into things, etc.)

My child has trouble learning new movements.
YesNo

My child tends to be clumsy and has balance and coordination problems.
YesNo


School History


Goals

Thank you for your time to help us better understand your child.  We look forward to meeting you. 

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