Data collection for rehabilitation services in schools

General information
Child Name: Date of birth (d/m/y): age :
sex : M F
address : School : preferred language :
other language spoken :
language spoken at home :
parent/guardian : home : cell :
work :
 Yes, You can reach me at work
parent/guardian : home : cell :
work :
 Yes, You can reach me at work
siblings (names and ages) doctor : day-care :
pediatrician : language spoken at the daycare :
Are you enrolled in a private insurance program?
Please specify :

Medical history
Name the major difficulties you encountered during your pregnancy if applicable:

Duration of pregnancy:
 Full term  Preterm ( weeks)  Post-term ( weeks)
Weight at birth :

Duration of labor :
Particularities :
 caesarean section  epidural  other :
 vaginal  induced

Were there any problems following the birth or during the first 2 weeks of life (health,
nutrition, sleep, etc…)? Please describe.

Please check all diseases / problems / surgeries your child has had:
 Allergies___________  Encephalitis  Tonsillitis
 Meningitis/Encephalitis  Convulsions  Epilepsy
 Blood disease :____  Muscle disorders  Neurological disorder
 Head injury  Heart problems  Adenoidectomy
 Bronchitis  Asthma  Rheumatoid Arthritis
 Ear infections  Dental problems  Ear tubes
 Surgeries :
Other/comments:

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Medical history (continued)

Has your child been seen by these specialists or received services?

Specialist Date Specialist name

 Audiology (ears, hearing)
 Ophthalmologist (eyes)
 Neurologist
 Ear, nose and throat (ENT)
 Speech language pathologist
 Psychologist
 Orthopedic/physiatrist
 Orthotist
 Occupational therapy
 Physiotherapy
 Social worker
 Optometrist
 Others (specify)
Other services
 IWK
 Stan Cassidy Center for Rehabilitation
 Early childhood stimulation
 Services for Children with special needs program
 APSEA (Atlantic Provinces Special Education Authority)
 Others (specify)

Has your child received a diagnosis? If so, please specify ____________________

Does your child take any medication? If so, please specify: __________________

Development :
At what age did your child:
Walk : Sit alone without help : Crawl on his hands and knees :
Potty trained : Say his first words : Say sentences :

Which is your child’s preferred drawing hand (or for other activities)? :
 Left  Right  Both

Please check the items that apply to your child.

General:
 Difficulty to follow a routine;
 Difficulty to socialize or get along with others;
 Difficulty sustaining attention;
 Gets frustrated easily;
 Activity Level abnormally high or low;
 Difficulty getting organized.

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Development (continued):
Occupational Therapy :
 Difficulty with drawing, coloring, cutting, avoiding these activities;
 Slow / difficult / awkward to manipulate objects;
 Very sensitive to touch, noise, odors, etc.;
 Difficulty holding a pen or eating with utensils, dressing without help, need help
toileting; Please specify:
___________________________________________________________;
 Needs equipment for school or home. Specify:
__________________________________;
 Difficulty with handwriting (difficulty to form letters; to form numbers);
 Difficulty copying from the board, copying shapes and drawings.

Other concerns:

If family members have had similar problems, please specify:

How can we help you?

 I would like an evaluation only.
 I would like an evaluation and recommendations for school and home.
 I would like suggestions and therapy to work with my child at home.
 I do not think my child has problems but the school has requested an evaluation.

Please add any information that could help us plan our visit with your child (i.e.: interests,
dislikes, phobias, personality traits, etc…):

Thank you for your cooperation.

Signature : Relationship : Date :

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 Home Room Teacher’s Questionnaire
Request for OCCUPATIONAL THERAPY Services

Name of student: ___________________ Date: ________________

Name of teacher: __________________ Completed by:
_________________________

To help us better prioritize students on the waiting list, please complete this questionnaire and
attach it to the Request for School-Based Rehabilitation Services
In the classroom: The student has difficulty …
 Following the class routine; Organizing his or her desk, work binder, locker;
 Maintaining a proper sitting position (listening position – work position).
 Copying from the blackboard (skips words, forgets letters in words)

Fine motor skills: The student has difficulty…

 Determining hand dominance; Grasping the pencil
 Speed of writing too slow compared to other students in the class
 Applying the proper pencil pressure (too heavy or too light); Erasing
 Cutting - grasping scissors and/or cutting out simple shapes (∆ О)
 Coloring – staying inside the lines; Drawing – copying simple shapes (∆ О X +)

Motor planning: The student has difficulty…

 Writing on the line or following margins; Leaving a space between words
 Writes from right to left
 Reproducing a multi-step action
 Following a sequence of movements (obstacle course)

Motor coordination: The student has difficulty…

 Holding the sheet when writing or drawing; Holding a ruler to draw a line;
 Catching a ball with two hands.

Activities of daily living: The student has difficulty…

 Dressing and undressing laces; buttons; zippers; other: _____________________
 Using the bathroom - toilet; wiping hand washing; other: _____________________
 Eating – using a fork; a spoon a knife; other: _____________________

Sensory integration: The student…

 Does not like loud or sudden noises;
 Is constantly moving, turning around, hitting, jumping, or climbing;
 Does not like getting his or her hands dirty;
 Needs to touch objects or people or avoids being touch by others;
 Has difficulty paying attention when working in a small group or in the classroom;
 Is constantly putting things in his or her mouth.

Other:
 The student wears glasses or hearing aids.
Please indicate the student’s total level of independence at school:
 Completely independent;

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  Needs to be accompanied by an educational assistant less than 50% of the time; more
than 50% of the time.
 The student is accompanied by an educational assistant on a full-time basis.

Which strategies have been attempted to respond to the problem:

______________________________________________________________________________________________
______________________________________________________________________________________________
________________________

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Fax/Téléc.: (506) 856-2320