Pediatric Connections

Please give a brief explanation of known trauma history (abuse, neglect, sexual trauma, etc.): If this information is better explained via phone or email please let us know. It's imperative that your therapist be informed PRIOR to the evaluation.

Who referred you to Pediatric Connections?

Why were you referred?

Family Information

Client lives with Please list all persons living in the home with names and relationship to client - including ages of all children in home.

Parent #1 Occupation

Parent #2 Occupation

Medical History

Was client born premature?

Describe birth history, including complications: If client is under 18

Medical conditions/allergies

Diagnosis (as given by MD)

Hearing/Vision Concerns

School/Home/Community

School name

School dist

Grade

Speech

Physical Therapy

Occupational Therapy

Counseling

Specialized Instruction

Other

None

Is client having difficulties at school? Please list areas of concern.

Is client having difficulties at home? Please list areas of concern.

Love and Logic

123 Magic

Connected Parenting

Time Out

Other

Is client having difficulties within the community (stores, unfamiliar places, etc)? Please list concerns.

Please place a check by thos characteristics you observe with your child. Please add comments or additional concerns:

Difficulty achieving & maintaining stability in sitting, standing, & during movement

Frequently "W" sits

Joints present as tight (limbs lack mobility)‎‎

Limbs lack mobility

Joints are extremely flexible (limbs very mobile)

Limbs are hyper mobile

Muscle tone appears typical to peers

Seeks sedentary play

Difficulty grading movement actions (i.e. uses couch or parent to stop movement)

Tends to seek support when sitting or standing

Tends to be fixed or "stuck" in posture

None noted

Always on the go, fidgety

Poor balance

Poor balance on uneven surfaces

Trips easily

Presents as clumsy

Poor lower body coordination

Poor galloping

Poor jumping jacks

Poor skipping

Poor running

Poor gait pattern

Walks on inside of feet

Walks on outside of feet

Walks on toes

Walks with toes inward

Walks with toes outward

Flat arches

Hip and knee problems

Unable to stand still; lacks grounding and stability

Issues with feet

Socks have to be just right

Prefers to go barefoot

Grinds teeth

Does not notice a mess on face when eating

Issues with fine motor coordination

Difficulties with gross motor coordination

Language delays

Timidity

Poor crawling patterns

None noted

Difficulty standing; poor grounding and stability

Uneven support of body weight on foot arches

Poor coordination for climbing

Poor coordination for jumping

Poor coordination for running

Poor coordination for swimming

Emotional instability and lack of self-confidence

Lack of ability to adapt for focus and change perspective, rigidity in thinking

Lack of flexibility

Difficulty letting go of stress and fears

Poor walking patterns

Unable to walk a straight line

Loses focus in walking

Unable to use a heel toe gait

Delay in articulation and speech development

Lack of self confidence in making choices

None noted

Difficulty coordinating legs to ride a bicycle

Hesitant when descending/climbing stairs

Hyperactivity

Poor coordination across the body mid-line/poor ability to cross crawl

Postural problems in general

None noted

Difficulty following verbal directions

Frequently asks for repetition of directions: Says "what" a lot

Slowed or delayed responses to auditory information

Frequently misunderstands

Does not consistently respond to their name

Difficulty sequencing events

Difficulty with attention, focus, and memory

Imbalance between focus and peripheral vision; does not get the big picture, focus tied to arms length

Disorganized approach to brushing teeth

Disorganized approach to preparing simple food

Disorganized approach to getting dressed

Letter and number reversals

Preferred hand is undetermined

Uncoordinated cross body movement: difficulty turning/rotating, twisting

Does not care for puzzles

None noted

Posture tends to bend forward or backwards; don't seem to have mid-line

Tendency to toe walk

Difficulty pushing up on toes and coming back down as when needing to reach something that is high up

Over focused on details, missing the big picture; "can't see the elephant in the room"

Emotional or irrational issues; talks without making emotional connections

Limited imagination

Timing of jumping is not there

Leans against external supports when sitting or standing

None noted

Difficulty dressing self (without fasteners) including socks/shoes due to lack of hand strength to pinch and pull up

Difficulty picking up small items

Difficulty with fasteners

Difficulty with buttons

Difficulty with snaps

Difficulty with zippers

Difficulty with tying shoes

Inefficient grasp of writing tools (pen/pencil)

Difficulty experiencing excessive pressure

Difficulty experiencing light pressure

Poor handwriting or written expression

Breaks pencils often

Difficulty with school tool for coloring

Difficulty with school tool for cutting

Difficulty with school tool for drawing

Difficulty with school tool for gluing

Inefficient grasp of scissors

Inefficient grasp of spoon

Inefficient grasp of fork

Inefficient grasp of knife

Prefers to eat with fingers

Unable to spread toppings with a knife

Poor speech and communication

None noted

Lack of arm, hand, eye coordination

Lack of body and space awareness/boundaries

Poor safety awareness

Poor social boundaries (aggressive, standoffish, isolated, easily becoming a victim, bully or being bullied)

None noted

Frequent injuries with falls (does not put hands out to protect self)

Poor socialization; giving and taking

Occulomotor control challenges (convergence & divergence i.e. copying from the board - far away to near)

Difficulty with eye hand coordination activities

Difficulty with bilateral hand skills (both hands)

Difficulty buckling pants/belt

Difficulty putting on pants/belt

Difficulty buckling seat belt

Difficulty with ball skills (i.e. catch/throw)

Difficulty pouring liquids

Difficulty with snaps

Difficulty climbing

Difficulty brushing teeth

Difficulty self feeding with utensils

Difficulty picking up small items

Difficulty lifting, pushing, pulling heavy objects

Head righting and vestibular issues (i.e. maintaining good postural alignment with head when body is off center)

Poorly regulated muscle tone in the arms (i.e. difficulty maintaining strength to hold something)

Poor fine motor coordination, difficulty with handwriting

Speech and communication delays

None noted

Associated oral reactions with hand utilization (i.e. tongue movements, lip movements or tightening of the lips. Tongue moves when cutting with scissors)

Biting/chewing on clothing/objects

Clenched fists

Eating challenges

Nail biting

Digestive issues

Difficulty blowing nose to clear

None noted

Becomes overly excited after movement activities

Seeks intense movement experiences

Motion sickness

Thrill seeker with little regard for safety

Breath holding with effort

Breath holding without effort

Rarely yawns

Yawns excessively/frequently

Shallow breath pattern

Mouth breather

Difficulty falling asleep

Difficulty staying asleep

Difficulty waking up

Excessive anxiety

Timidity

Maladaptive patterns of self protection

Lack of trust

Fear of taking risks required for learning

Fearful of feet leaving the ground when in control of the activity

Fearful of feet leaving the ground when out of control of the activity

Hypersensitivity to vestibular stimulation; does not like his head tipped back (hair washing in bathtub)

Motion sickness

Poor adaptability

Poor balance

Problems with choice making

Weakened immune system

None noted

Fearful of or startles to touch stimuli

Fearful of or startles to visual stimuli

Fearful of or startles to auditory stimuli

Overly sensitive to loud noises

Overly sensitive to visual stimuli

Dislikes having their vision occluded

Difficulty completing tasks when sounds are nearby

Hears sounds that others do not hear

Excessive anxiety, timidity, maladaptive patterns of self protection, lack of trust

Fails to read visual cues in the environment

Holds body stiffly

Hyperactive gag responses

Hyperactivity in general

Resistive to brushing teeth

Resistive to dentist

Resistive to haircuts

Resistive to nail trimming

Visually distracted

Difficulty with ball skills

None noted

Leans on people/objects for stability

Poor differentiation of pelvis from spine (i.e. hips and spine move together)

Low back tends to be stuck in extension

Unable to assume superman position on their belly

Delayed crawling in developmental history

Delayed walking in developmental history

Atypical walking pattern (stiff)

Atypical walking pattern (lacks reciprocal arm movement)

Atypical walking pattern (waddles)

Atypical walking pattern (leans forward)

Spinal deformities

Tactile hypersensitivity

Auditory hypersensitivity

Short and long term memory difficulties

Plays rough with people and objects

Has difficulties grading their actions; too fast/slow, too hard/soft

Bladder issues (bed wetting)

Bladder issues (potty training)

Complains of stomach pains

Picky eater

Breath holding with effort or novel activity

None noted

Poor sequencing skills: challenges with space and time

Poor cause and effect awareness

Gets car sick: vestibular problems

Did not crawl as an infant

Locks legs in standing to maintain posture

Hyper muscle tone (high)

Hypo muscle tone (low)

Avoids sports

Trouble throwing a ball

Tends to slide out of their chair and under the table or desk

Seeks head banging

Visual issues with focus and tracking

None noted

Poor muscle tone

Difficulty concentrating

Clumsy in movements

Stands with locked knees

Hard to understand new things

None noted

Asymmetrical gait pattern (i.e. arms/legs do not swing in a cross body pattern)

Poor orientation in space

Poorly developed perspective, vision

None noted

Slow study pace with academics

Deficits in auditory processing

Discomfort in auditory processing

Hyperactivity

Difficulty with control of bowel and/or bladder, bed-wetting, irritable bowel syndrome

Abnormal gait with incorrect hip rotation

Poor concentration

Poor gross motor coordination

Scoliosis

Tendency to adjust body/forget frequently when sitting in a chair

Falls out of their chair

None noted

Wears glasses

Difficulty visually tracking

Poor eye tracking

Keeps eyes close to paper

Poor visual monitoring of hand during fine motor tasks

Difficulty finding objects in competing backgrounds

Difficulty moving hands, arms, head separately; tends to move as one unit

Reactivity between head and muscles of the arms

Puts head down excessively when drawing

Puts head down excessively when reading

Puts head down excessively when writing

Prefers to stand to engage in hand activities

Poor balance, spatial or temporal awareness

Prefers sedentary play

Problems with athletics/avoids new physical challenges

Social issues; under achievement, frustration, avoidance

Wraps feet around front legs of chair

None noted

Phobias of heights

Gravitational insecurity: does not like their feet to leave the ground

Unable to jump effectively

Impulsive jumping; jump all the time

Challenged to judge height and depth

Lacks control in dangerous situations

None noted

Goals

It is important that we partner in establishing goals for therapeutic intervention. Please list the top priorities we can address first:

Goal #1

Goal #2

Goal #3

Goal #4

Your Child's Strengths:

Your Child's Challenges:

Any other comments/concerns not addressed above?

Processing Form

Pediatric History

Family Information

Medical History

School/Home/Community

Please place a check by thos characteristics you observe with your child. Please add comments or additional concerns:

Goals

It is important that we partner in establishing goals for therapeutic intervention. Please list the top priorities we can address first: