OCCUPATIONAL THERAPY

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OCCUPATIONAL THERAPY Powered By Docstoc
					_____________________________________________________________________________________________________


                                    Michelle Robbertse
                                  Occupational Therapists
                                     Arbeidsterapeute
                                       PR: 0234958
E-mail: robberm@gmail.com                                                Tel : 083 573 5921 / 012 548 6410
Website: www.ot4you.com                                                           Fax : 086 513 2793
_____________________________________________________________________________________________________
  Please complete all the questions and send it in an envelope to the teacher, stating “ FOR ATTENTION
                                    MICHELLE OCCUPATIONAL THERAPIST”
     I need to know all this information to understand your child and to give him/her the best possible
                                                   treatment.
                               All information is handled as strictly confidential!

1.      PERSONAL INFORMATION OF YOUR CHILD:
Full names of child:                                 School:
Surname of child:                                    Teacher:
Birth date of child:
Age:                years        months              Home language:
Gender of child:
Who referred your child to Occupational Therapy?_____________________________________________________
What was the reason for the referral?_________________________________________________________________
___________________________________________________________________________________________________


2.       FAMILY STRUCTURE:
If parents are not divorced, please complete:
2.1                  Name                     Age          Occupation                     Work
Father
Mother
Brothers
Sisters
Other people
that live with the
family

If parents are divorced, please complete:
                     Name                     Age           Occupation                    Work
Father
Stepmother
Mother
Stepfather
Brother(s)
Sister(s)
Stepbrother(s)
Stepsister(s)
Other people that
live with the
family

      Date of divorce:_______________________________________________________________


                                                                                                         1
         How often does the child visit the parent whom he does not stay with:_______________________
          __________________________________________________________________________
         Structure of family where the child stay:____________________________________________
          ___________________________________________________________________________
         Structure of family where the child doesn’t stay:______________________________________
          ___________________________________________________________________________


2.2     Describe the relationship between your child and the following people:
Mother:
Father:
Brother(s):
Sister(s):
Grandmother(s):
Grandfather(s):
Nanny:
Between parents:
Stepparent(s):
Stepbrother(s) /-sister(s):

2.3       Describe how you discipline your child at home:______________________________________
3.      PREGNANCY: Did the mother experience any of the following?
Anemia                              No      Yes    Virus infections                               No     Yes
High blood pressure                 No      Yes    Other illnesses                                No     Yes
Toxemia                             No      Yes    Vomiting                                       No     Yes
Swollen ankles                      No      Yes    Injuries                                       No     Yes
Kidney problems                     No      Yes    Medication used                                No     Yes
Heart problems                      No      Yes    Placenta dysfunction                           No     Yes
Early Contractions                  No      Yes    Emotional problems                             No     Yes
Measles                             No      Yes    Other problems                                 No     Yes

4.       BIRTH: (Please circle the appropriate answer)
Was the baby born early? (Premature)          Yes    No     Describe:
Full term                                     Yes    No
Post term                                     Yes    No
Normal birth?                                 Yes    No
Caesarian                                     Yes    No
Induction                                     Yes    No
Instruments                                   Yes    No
Medication during labor                       Yes    No
Breathing problems (baby)                     Yes    No
Cord around the neck                          Yes    No
Wrong position                                Yes    No
Did the baby cry immediately after birth?     Yes    No
Was the baby’s color normal?                  Yes    No
Was the baby in an incubator?                 Yes    No     Period?
Birth weight                                            kg
Apgar score                                       /10      /10




                                                                                                           2
.       DEVELOPMENTAL HISTORY:

5.1     Motor Developmental Milestones:                 Age   Describe
Sit       a) With help
           b) Without help
Crawl      a) For how long period?
           b) Other ways of crawling?
           c) Was your child in a walking ring?
Walk       a) With help
           b) Without help
           c) Run

5.2      Dominance (Children older than 4 years)
Which hand does your child use to draw, write, catch, grab with most     Left     Right   Left & Right
of the time?

Is anyone in the family lefthanded?_________________________________________________________

5.3 Balance system                                            Age      Describe
Is/was your child scared when thrown in the       Yes   No
air?
Is/was your child scared of lifts, stairs?        Yes   No
Did your child easily learn to ride a bike?       Yes   No
Does your child easily get car sick?              Yes   No

5.4 Reaction to physical contact                              Age      Describe
Does your child like being touched?               Yes   No
Dislikes washing hair/face?                       Yes   No
Does he/she become irritated when his/her         Yes   No
hands are dirty?
Dislikes certain textures of clothing?            Yes   No

5.5 Muscle Control                                            Age      Describe
Does your child easily get tired when standing    Yes   No
or sitting for long periods?
Does your child fall or stumble a lot?            Yes   No

5.6 Visual functioning                                        Age      Describe
Does your child have a visual problem?            Yes   No
Does he/she wear spectacles?                      Yes   No
Does he/she appear sensitive to light?            Yes   No
Does he/she work with his/her head too close      Yes   No
to the table?

6.       LANGUAGE AND COMMUNICATION SKILLS-Specifically in English:
Does your child:                                         Describe
Understand English well?                 Yes   No
Leave sounds out? (Example. ghetti for   Yes   No
spaghetti)
Switch sounds? (tap/pat)                 Yes   No
Stutter?                                 Yes   No
Does your child have grommets in his/her Yes   No
ears? When?
Did your child’s eardrum burst? When?    Yes   No



                                                                                                         3
7.        EMOTIONAL DEVELOPMENT:
Mark the appropriate boxes:
Irritated                 Speaks a lot               Aggressive towards     Cant play quietly
                                                     other
Cant sit still            Sleeping problems /        Withdrawn              Emotions vary a lot.
                          Nightmares                                        Cries easily.
Attention easily          Anxiety/fear eg for the    Over-active behavior   Anxiousness.
distracted                dark, to be alone, etc.                           Chews/Bites nails. Sucks
                                                                            thumb…
Poor Self Image           Disruptive behavior        Tell lies / steal

7.1    How do you experience your child emotionally?: (eg. Loving, sensitive, aggressive etc…)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_____________________________________________
8.       MEDICAL HISTORY:
                                                        Age      Describe
Childhood diseases e.g. Meningitis,      Yes    No
Encephalitis, Measles, Chicken pocks,
etc.
Fever                                    Yes    No
Unconscious due to head bump…            Yes    No
Allergies                                Yes    No
Tonsillitis                              Yes    No
Sinusitis                                Yes    No
Asthma                                   Yes    No
Head Injuries                            Yes    No
Hospitalization                          Yes    No
Operations                               Yes    No
Physical abnormalities                   Yes    No
Electro encephalogram (EEG)              Yes    No
Cat Scan                                 Yes    No
Other procedures                         Yes    No

9.       MEDICATION:

9.1  Current medication:
Name                 Dosage     Reason                    Positive affect     Negative effect




                                                                                                  4
10.     PREVIOUS EVALUATIONS:
Mark the appropriate block. State the date of the evaluation. If   possible, please send report(s) to me.
Pediatrician           Speech Therapist     Occupational            Psychologist           Neurologist
Name of Doctor:        Name of              Therapist               Name of Therapist:     Name of Doctor:
_______________        Therapist:           Name of                 _______________        _______________
Date of visit:         _______________      Therapist:              Reason for referral:   Date of visit:
_______________        Reason for           _______________         ___________________ _______________
Reason for visit:      referral:            Reason for              __________________     Reason for visit:
_________________      ________________     referral:               Date of onset:         _________________
___________________ ________________        ________________        _______________        ___________________
                                            ________________        Date and reason
                         Date of onset:     Date of onset:          why therapy was
                         _______________    _______________         terminated:_______
                         Date and reason    Date and reason         __________________
                         why therapy was    why therapy was         ___________________
                         terminated:______ terminated:______
                         _________________ _________________
                         _________________ _________________
Other:


11.      SCHOOL:

Please circle the appropriate sentences and give more information:

11.1     My child likes school / does not like school. He/she don’t want to go to school
         sometimes___________________________________________________________________
11.2     Is there any problems at school?:_________________________________________________
         ___________________________________________________________________________
11.3     Which extra curricular activities do your child participates in at school?___________________
         ___________________________________________________________________________
11.4     Does your child write his/her name in mirror image?_______________________________
11.5     Does your child reverse letters such as b and d when writing?________________________
11.6     Does your child reverse letters such as b and d when reading?________________________
12.      GENERAL:

12.2     How does your child socialize with friends? Does he/she make friends easily?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________________________________________________________
12.3     Other extra curricular activities: (not at school)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________________________________________________________




                                                                                                            5
                                 HOME PROGRAMME QUESTIONNAIRE
   1. Please describe your child’d weekly routine by fcompleting the blocks below. Also add extra murals.

                  Monday        Tuesday        Wednesday     Thursday       Friday       Saturday
   05:00
   06:00
   07:00
   08:00
   09:00
   10:00
   11:00
   12:00
   13:00
   14:00
   15:00
   16:00
   17:00
   18:00
   19:00
   20:00

   2. How much time do you have to carry out the home programme with your child on the following days:

      Monday: ___________
      Tuesday: ___________
      Wednesday: ________
      Thursday: __________
      Friday: ____________
      Saturday: __________

2. Does your child have and play with the following? (Mark X in the appropriate block)
     PC games 
     Wii 
      Playstation 2/3 
      Playstation move 
      Other______________

If yes, indicate how much time your child spends playing these games per weekday and weekends:
      Time spent weekdays (per day-general estimate) _______
      Time spent weekends and holidays (per day-general estimate) _______


3. On average, how much time PER DAY does your child spend watching TV/DVDs?
     Weekdays ________________
      Weekends and holidays_____________

4. Does your child do any household chores or help you with any household activities? If so, please name
the activities: _______________________________________________________________
________________________________________________________________________________


5. Does your child dressand bath him/herself or do you help him/her?________________________
__________________________________________________________________________________
6. Does your child sleep in his/her own bed?_____________________________________________
7> Does your child still wet his/her bed at night?__________________________________________

                                                                                                           6
     3. Please complete the following list to give us an indication of the resources that can be used to
        compile a home programme for your child:

     Please note, you are under no obligation to buy all of this equipment, we would just like to know what
     you have at home so that we can utilize all physical equipment maximally.
√      APPARATUS                                                  COMMENTS
       Gym/Exercise Ball
       Please indicate the size of the ball: 45cm/ 55cm/
       75cm
       Hammock
       Trampoline Large
       Trampoline small
       Bopping ball/animal/Hoppity ball
       Skateboard
       Trapeze (Swing created from an elevated horizontal
       bar)
       Free standing swing
       Suspended rope ladder (Rope hanging from a
       tree/veranda)
       Stilts/2 tins with attached ropes for child to hold on to
       Suspended rings to hang on
       Weighted ball/ Medicine ball
       Skipping rope
       Mattress
       Mirror (preferably: 90cm x 90cm)
       Please indicate the size of the mirror you have if not
       90x90cm.
       Black board/white board
       Pool noodle
       Scoops/2xstaysoft bottles
       Heavy blankets
       Different size balls including tennis balls
       Bean bags
       Cones/ Plastic bottle filled with sand
       Lawn
       Please indicate the size of the lawn area you have
       available.
√      PARK /PLAYFIELD WITH APPARATUS NEAR BY                     COMMENTS
       Slide
       Merry go round
       Jungle Gyms
       See-saw
       Sandpit
       Swings



    PLEASE INCLUDE ANYTHING YOU OWN THAT MAY BE USEFUL THAT IS NOT MENTIONED ABOVE




                             THANK YOU FOR YOUR TIME AND COOPERATION!

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posted:11/4/2012
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