Occupational Therapy Supplement

Please Submit this form prior to your appointment with Capable Kids.

    Name (required)





    Child's name



    SLEEP

    What time does your child wake up?


    Falling asleepStaying asleep


    DRESSING


    ShirtPantsUnderwearShoesSocksCoat


    ShirtPantsUnderwearShoesSocksCoat


    SnapsZippersButtons (unbutton & button) Tie Shoe laces


    GROOMING


    Tooth brushingBathingHair brushing/combingHaircutsFace washingNail trimmingBlowing nose


    Tooth brushingBathingHair brushing/combingHaircutsFace washingNail trimmingBlowing nose




    TOILET TRAINING


    YesNo




    FEEDING / ORAL MOTOR / RESPIRATION


    YesNo

    Did your child have reflux?


    SpoonForkKnife


    SOCIAL FUNCTIONING

    Are you limited in attending family/social gatherings because of your child’s behaviour/reactivity to events? YesNo
    Comments:

    Is your family unable to maintain relationships with other families? YesNo
    Comments:

    Is the child able to tolerate social touch or hugs from others? YesNo
    Comments:

    Does the child have difficulties with other people’s voices? YesNo
    Comments:

    Impact on child:



    SOCIAL INTERACTIONS

    Does your child appear to have an awareness of others? YesNo
    Comments:

    Does your child appear to have an awareness of self? YesNo
    Comments:

    How does your child react in new/unfamiliar situations?

    Does your child have difficulties paying attention in noisy environments? YesNo
    Comments:

    Does your child regularly avoid initiation of social interaction? YesNo
    Comments:

    Is your child able to maintain social interactions? YesNo
    Comments:

    What happens if routine is disrupted? YesNo
    Comments:

    Does your child exhibit aggressive behaviour? YesNo
    If yes:

    Is it directed at him/herself? YesNo


    BitingPinchingKickingHittingOther(s)


    Does your child exhibit tantrums? YesNo
    How frequently do they occur?

    time/day OR

    Are tantrums a source of distress to other family members? YesNo


    Is your child easily frustrated, anxious or overwhelmed? YesNo



    Is your child overly dependent on parent(s) or clingy? YesNo




    Does your child easily escalate from a whimper to intense cry? YesNo




    Hand flappingRockingHead bangingJumpingSmellingBreath holdingHummingSelf-talkBitingMouthing objectsVisual fixingSpinningTeeth grindingOther(s)


    Does your child struggle when there is excessive auditory input in his/her environment? YesNo



    Does your child struggle to communicate his/her own needs? YesNo




    TalkingSingingSounds / vocalisationPointing / gesturingCrying / screaming


    PLAY SKILLS/PEER INTERACTION
    How long is your child able to play alone (minutes)? 1-22-55-1010-30

    How much time is spent in the following activities?





    Does your child struggle playing with other children? YesNo

    Parallel play – alongside othersInteractive play – playing with othersStructure group playMaking FriendsPretend play


    Is your child preoccupied with seeking intense movement during play? YesNo

    SpinningBouncingCrashingJumpingRockingOther(s)


    COMMUNITY

    Is your child able to eat at restaurants? YesNo
    Comments:

    Is your child uncomfortable on elevators, escalators or in cars? YesNo
    Comments:

    Does your child avoid busy, unpredictable environments? YesNo
    Comments:

    Does your child have excessive reaction to light touch? YesNo
    Comments:

    Is your child unresponsive to being touched or bumped? YesNo
    Comments:

    Does your child have an excessive reaction to being bumped unexpectedly? YesNo
    Comments:

    Does your child lack safety awareness? YesNo
    Comments:

    Does your child have difficulty with loud, crowded sporting events? YesNo
    Comments:

    Does your child have difficulty sitting through public performances? YesNo
    Comments:

    Does your child have difficulty in the grocery store or shopping malls? YesNo
    Comments: