Enclosed Forms Evaluation The following items have been enclosed

Enclosed Forms (Evaluation) The following items have been enclosed, but do not need to be returned to the Philo Center: Directions ▪ Notice of Privacy Practices for Protected Health Information Items which have been enclosed and need to be returned before scheduling an evaluation appointment have been indicated below. When returning the forms, please indicate which forms you have enclosed by checking the boxes below and returning this checklist with your forms. If you think a form is inappropriate for your child, please contact the Philo Center to discuss this before opting not to complete that form. If you have any questions, please call us at (802) 985-8211. Authorization and Acknowledgement of Receipt of Notice of Privacy Practices Evaluation Payment Contract Evaluation Policies Food Inventory (if identified feeding issues) Functional Skills Checklist Physician's Referral Form *for insurance reimbursement Sensory and Developmental History Sensory Profile must be filled out completely School Checklist (To be completed by a teacher or other school official) * The physician’s referral form is only needed if you are planning on getting reimbursed by insurance. For insurance reimbursement, please bring your insurance card at the time of your visit. General Philo Information Directions From I-89 North or South Take exit 13 South (Shelburne/Vergennes) to I-189. Take I-189 to Route 7/Shelburne Rd. Go left at the light at the end of the exit ramp (Route 7 South), towards Shelburne and Vergennes. Go through South Burlington to Shelburne. Philo is exactly 3.7 miles from the exit ramp to the parking lot entrance, just past the Yankee Doodle Motel. If you miss the first entrance, there is a sign on the right and a traffic light at the intersection of the far entrance. Turn right into the parking lot, then bear right towards the yellow building (you can park here). We are through the green double doors about halfway down the yellow building (suite E); there is a Philo Center sign outside. From Route 7 North Follow Route 7 North to Shelburne. You will pass the Shelburne Museum on your left. From the traffic light in the village of Shelburne (Mobil station on left), Philo is about 1.2 miles on your left. There is a sign on the left for Shelburne Commons. Turn left at the light, then bear right toward the yellow building (you can park here). We are through the green double doors about halfway down the yellow building (suite E); there is a Philo Center sign outside. Philo Holidays New Year's Day Martin Luther King Day Memorial Day Independence Day Labor Day Thanksgiving Day Thanksgiving Friday Christmas Eve Christmas Day Half day on New Year's Eve 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 WWW.PHILOCENTER.ORG Notice of Privacy Practices for Protected Health Information THIS NOTICE DESCRIBES HOW OCCUPATIONAL THERAPY, AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice explains how your protected health information may be used and disclosed to carry out payment and health care operations and for other purposes that are permitted or required by law. “Protected health information” in this notice means any personally indentifiable information, including demographic information, that may be gathered in evaluating your current condition, making a diagnosis, deciding a course of treatment, assessing your progress, coordinating care with other health service providers, and documenting and obtaining payment for services provided. The Notice also outlines your rights to request restrictions on disclosures, to receive an account of disclosures, and to review and request amendments to your health information. (This Notice is provided in compliance with the Privacy Regulation resulting from the Health Insurance Portability and Accountability Act, 1996.) How we may use or disclose your health information… The following are ways we may use or disclose your health information. Assessment and Treatment. We may use your health information to evaluate your current condition, to make a diagnosis, to determine a course of treatment, and to monitor and assess the progress of your treatment, as well as to coordinate care with other health service providers as may be appropriate. Obtaining Payment. We may use and disclose your health information to obtain payment for services provided. This may entail communicating with an insurance company or managed care organization, or working with a billing agency or clearinghouse. All these entities and business associates are obligated to protect the privacy of your health information. Health Care Operations. We may use or disclose your health information for health care operations that are necessary to assess quality of care and effectiveness of treatment services. We may send you a reminder that you have an appointment. We may tell you about alternative treatments and programs or about services that may be of interest to you. Special use and disclosure situations… We may also use and disclose health information about you when required to do so by federal state or local law. Circumstances where information may be disclosed include the following: Abuse or Neglect. We may disclose your health information to a public health authority, or other government authority authorized by law to receive reports of child or elder abuse, neglect or domestic violence consistent with the requirements of applicable federal and state laws. Criminal Activity. We may disclose your health information when necessary to prevent or lessen serious and imminent threat to the health and safety of a person or the public. Legal Proceedings. We may disclose your health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized) and, in certain situations, in response to a subpoena, discovery request or other lawful process. Public Health. We may disclose your health information for public health activities. These activities include preventing or controlling disease, injury or disability; reporting births or deaths; or reporting reactions to medications or problems with medical products. Health Oversight. We may disclose your health information to a health oversight agency that monitors the health care system and government programs for designated oversight activities. Workers' Compensation. We may disclose your health information as authorized to comply with workers' compensation laws and other similar legally established programs. 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 WWW.PHILOCENTER.ORG The Philo Center Notice of Privacy Practices Your rights regarding your health information… The following are your rights with respect to your health information. Right to Request Restrictions. You have the right to request in writing additional restrictions or limitations on the use or disclosure of your health information. While we will try to honor your request, we are not legally required to agree to these additional restrictions or limitations. If we agree, we will comply with your request or limitations except in emergency situations. Right to Request Confidential Communications. You have the right to request that we communicate with you about your health information in a certain way or at a certain location if disclosure of information could endanger you. We will accommodate your reasonable request. Right to an Accounting of Disclosures. You have the right to request in writing an accounting of disclosures of your health information except for those necessary to carry out payment and health care operations, disclosures made to you, or in certain other situations. Right to Inspect and Copy Health Information. You have the right to inspect and obtain a copy of certain health information that we maintain to make decisions about your care. We may charge you a reasonable fee for copying, postage, and supplies used to meet your request. You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to inspect and/or copy your health information to be in writing. Right to Amend. If you feel that the health information we maintain about you is incomplete or inaccurate, you may ask me to amend the information. This request must be in written form. In certain circumstances we may deny your request. If we deny the request, we will provide a written explanation and advise you of your right to file a written statement of disagreement. If we approve your request to change the information, we will include the change in your health information and make reasonable efforts to tell others that need to know about those changes and to include the changes in future sharing of that information. How you may exercise your rights… You may request restrictions of disclosures, accounting of disclosures, amendments to your health information or to inspect or copy your health information, by submitting your request in writing to us. We will obtain a written authorization for any use or disclosure of your health information that is not identified in this notice. If you authorize us to use or disclose your health information, you may revoke your authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your authorization; however, we will not reverse any use or disclosure already made in reliance on your authorization before it was revoked. You have a right to receive a paper copy of this notice and may ask for a copy at any time. We reserve the right to change the terms of this notice at any time, consistent with applicable law. Those changes will be effective for health information previously obtained and for future information about you. Once the notice is revised, we will provide the new notice to you. If you have any questions about this privacy practices notice, please speak with or write to us at the address below: The Philo Center 4066 Shelburne Rd, Ste 8 Shelburne, VT 05482 802 985 8211 If you should believe that your privacy rights have been violated, you may file a complaint with us in writing. You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. You will not be penalized for filing a complaint. Page 2 Authorization and Acknowledgement of Receipt of Notice of Privacy Practices This notice will expire seven years after the date upon which the record was created. By signing below, I acknowledge that I have received a copy of this notice. I understand that if the person or entity that receives this information is not a health plan or health care provider covered by federal privacy reculations, the released information may be re-disclosed by the recipient and may no longer be protected by federal or state law. I understand that I may revoke this authorization at any time by notifying my provider in writing. However, if I choose to do so, I understand that my revocation will not affect and actions taken by my provider before receiving my revocation. I understand that I may refuse to sign this authorization and that my refusal to sign in no way affects my treatment, payment, enrolment in a health plan, or eligibility for benefits. I understand that by signing this form I am confirming my authorization for use and/or disclosure of the protected health information described in this document with the people and/or organizations named above. Client name (printed) Client Signature Date For Parent/Representative of Client (if applicable) Personal representative (printed) Personal representative signature Relationship of representative (parent, guardian, etc.) Date Authorization for Use and/or Disclosure of Protected Health Information and Release of Information for Team Collaboration 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 WWW.PHILOCENTER.ORG Your signature at the end of this form authorizes the use or disclosure of your child’s protected health information for the special purpose(s) defined below. I hereby authorize the use and disclosure of individually identifiable health information relating to my child, which is called “protected health information” under a federal health privacy law, as described below: Please list: People and/or Organization(s) (with addresses) Authorized to Release Protected Health Information to Philo People and/or Organization(s) (with addresses) to Whom Philo is Authorized to Disclose Protected Health Information Same as above Other: Specific Description of the Information to be Used or Disclosed unless otherwise indicated: Current and continuing relevant documentation such as meeting minutes, progress notes, and evaluations. The Protected Health Information Will be Used and/or Disclosed for the Following Purposes, unless otherwise indicated: To facilitate discussion of my child’s progress and conversation regarding my child’s programming between service providers and my child’s therapist(s) at the Philo Center. I am the Representative’s Relationship of Client’s Name . I understand that as part of my child’s health care, my child’s therapist creates and maintains records describing my child’s health history, symptoms, examination and test results, diagnoses, treatment plans and progress, and notes related to coordination of care with other health care providers. I understand that this information serves as: a basis for planning my child’s care and treatment, a means of communication among the health professionals who contribute to my child’s care, a source for applying my child’s diagnosis and other health information to my bill, a means by which my health insurance plan or other payment source can verify that services billed were actually provided, and a tool for routine health care operations such as assessing the quality of care and effectiveness of treatment I have the right to revoke this consent, in writing, at any time, except that to the extent that the Philo Center has acted in reliance on this consent. Signature of parent or legal guardian Parent or legal guardian (printed) Date Page 2 Evaluation Payment Contract An occupational therapy evaluation for __________________________________ will be scheduled upon receipt of the enclosed forms. I understand that the appointment will take approximately 3 hours. I understand that the cost, including documentation and follow-up consultation, will be $900.00 and that one half ($450.00) of this balance is due at the time of the appointment (payable by cash, check, Visa or Mastercard), and the second half ($450.00 is due upon receipt of the invoice. I also understand that I will not receive the written evaluation report until I have paid in full. Due to staffing constraints, The Philo Center does not bill private insurance companies. However, at your request, we will provide you with a form to submit for reimbursement. Philo Center therapists’ schedules are carefully developed to maintain efficiency while providing them with an optimal workload. Thus it is key that we are informed in advance of any cancellations. I understand that if we do not cancel and miss a scheduled appointment, the person responsible for transportation will be charged $450.00 to compensate for the therapist’s time. Signature of Parent or Adult Client if responsible for payment Signature and Title of Party Responsible for Payment if other than parent Billing Information: Name: Address: Phone Number: Fax Number: E-mail Address: ____________________________________ WWW.PHILOCENTER.COM 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 Evaluation Policies Client Name: I understand that unless I have paid for the evaluation in full, I will receive a bill for the remainder of my balance due before I will receive the written evaluation report. Initials ______ I understand that if another organization or person has agreed to pay for services, The Philo Center must receive prior written authorization from them before the evaluation can take place. I also understand that I am ultimately responsible for payment if the before mentioned does not pay for the service. Initials ______ I understand that this clinic is willing to provide additional calls or meetings following the evaluation if requested. I understand these additional services will be billed at the standard hourly fee for the Philo Center. Initials _______ I understand that a physician’s report or letter of referral is required for obtaining insurance reimbursement. If insurance coverage will be used for services, I am responsible for submitting forms to the insurance company if needed and paying this clinic directly on the day of service. The Philo Center therapist will assist in obtaining insurance coverage by writing reports and letters to insurance companies. A fee equal to one-half of the hourly treatment rate is charged for insurance letters Initials _______ Acknowledgment of Risk I acknowledge that there is some risk inherent in the use of the therapy equipment at this clinic, and I agree to indemnify and hold The Philo Center harmless from any and all losses and claims for any injuries or other damages occurring to myself or my child or our belongings from the use of therapeutic equipment. Initials _______ Parent/Guardian/(Adult) Client Signature Date 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 WWW.PHILOCENTER.ORG Physician's Referral Form Patient Name: Physician’s Name (printed): Diagnosis: Please check one of the following. If more than one diagnosis applies, please star ( ) the most important. Apraxia (784.69) Lack of Coordination Disorder (781.3) Dyspraxia Syndrome (315.4) _____Autism (299.0) _____PDD NOS (299.9) _____Asperger’s Syndrome (299.8) Other (Diagnosis Code Required): Occupational Therapy is prescribed for the following (check as many as appropriate): Evaluation: Developmental Evaluation Functional Skills Assessment Sensory-Motor Processing/Sensory Integration Evaluation Evaluation of Visual-Motor Abilities Evaluation of Perceptual Abilities Dynamic therapeutic activities and/or neuromuscular re-education to address sensory-motor and fine motor coordination difficulties Sensory integrative therapy ADLs and self-care Adaptive equipment or splinting Date: Patient Date of Birth: Treatment: Physician's Signature: Address: 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 WWW.PHILOCENTER.COM Functional Skills Checklist I = Independent S/U = Independent with Setup SV = Supervision or Prompts PA = Physical Assistance D = Dependent N/A = Not Applicable I Food Textures Eats pureed/blended/strained foods Eats ground/lumpy foods Eats cut up/chunky/diced foods Eats all textures of table food Use of Utensils Finger feeds Scoops with a spoon and brings to mouth Uses a spoon well Uses a fork well Uses a knife to butter bread, cut soft foods Uses a knife to cut all foods Use of Drinking Containers Holds bottle or spout cup Lifts cup to drink, but cup may tip Lifts open cup securely with two hands Lifts open cup securely with one hand Pours liquid from carton or pitcher Drinks from a straw Toothbrushing Opens mouth for teeth to be brushed Holds toothbrush Brushes teeth; but not a thorough job Thoroughly brushes teeth Prepares toothbrush with toothpaste Spits out toothpaste but not a thorough job Spits out toothpaste effectively Hairbrushing Holds head in position while hair is combed Brings brush or comb to hair Brushes or combs hair Manages tangles and parts hair Manages barrettes and hair ties Nose Care Allows nose to be wiped Blows nose into held tissue Wipes nose using tissue on request Wipes nose using tissue without request Blows and wipes nose effectively without request 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 WWW.PHILOCENTER.ORG S/U SV PA D N/A Handwashing Holds hand out to be washed Rubs hands together to clean Turns water on and off, obtains soap Adjusts temperature of water Washes hands thoroughly Dries hands thoroughly Scrubs and files nails Washing Body & Face Takes bath or shower Regulates water temperature Tries to wash parts of body Washes body thoroughly, not including face Obtains soap (and soaps washcloth, if used) Dries body thoroughly Washes and dries face thoroughly Washes hair Shave/apply cosmetics and deodorant Laundry Uses washer and dryer Folds clothes Irons clothes Puts clothes away Pullover/Front-Opening Garments Assists, such as pushing arms through shirt Removes T-shirt, dress or sweater (pullover garment without fasteners) Puts on T-shirt, dress or sweater Puts on and removes front-opening shirt, not including fasteners Fasteners Tries to assist with fasteners Zips and unzips, doesn't separate or hook zipper Snaps and unsnaps Buttons and unbuttons Zips and unzips, separates and hooks zipper Snaps and unsnaps corsets/bra hooks Puts on ties and cuff links, ties bowties Pants Assists, such as pushing legs through pants Removes pants with elastic waist Puts on pants with elastic waist Removes pants, including unfastening Puts on pants, including fastening Adjusts pants Shoes/Socks Removes socks and unfastened shoes Puts on unfastened shoes Puts on sneakers, other shoes Puts on socks Adjusts and orients socks correctly -2- Puts on shoes on correct feet; manages velcro Ties shoelaces Toileting Tasks Assists with clothing management Tries to wipe self after toileting Manages toilet seat, gets toilet paper and flushes toilet Manages clothes before and after toileting Wipes self thoroughly after bowel movement Uses a public toilet Manages menstrual aides Management of Bladder Indicates when wet in diapers or training pants Occasionally indicates need to urinate (daytime) Consistently indicates need to urinate with time to get to toilet (daytime) Takes self into bathroom to urinate (daytime) Consistently stays dry day and night Management of Bowel Indicates need to be changed Occasionally indicates need to use toilet (daytime) Consistently indicates need to use toilet with time to get to toilet (daytime) Distinguishes between need for urination and bowel movements Takes self into bathroom for bowel movements, has no bowel accidents Functional Communication Answers yes or no questions Responds to greetings Asks for help Uses gestures effectively Speaks in single word "phrases" Makes a request or simple statement Uses speech for requesting Uses speech to say no Uses speech for social interaction Uses speech to bring attention to oneself Uses speech for commenting/sharing information General Activities Goes up and down stairs Opens and closes door Can legibly write name in cursive or print within this sized box Can dial 9-1-1 Can communicate name, address, and phone number Able to stay home alone for minutes / hours Aware of maintaining safe proximity with an adult (does not wander or bolt) Crosses street safely Manages medications -3- Accesses public transportation Rides a bike with training wheels Rides a bike without training wheels Uses alarm clock Identifies street signs and road crossings Buys something in a store Recognizes when correct change is given Prepares a simple snack Uses a microwave Uses a stove top Can cook with appliances (unsupervised) Goes to dentist and physician appointments Use electric switch effectively Leisure skills: If left alone, how does he or she occupy his or her time? Academic Abilities Grade in School: Writing Math More than 2 years below grade level Between 1 and 2 years below grade level 1 year below grade level On grade level Above grade level Therapist Section Standardized Scores VMI Breuninks-Osteretsky Coordination and Visual-Motor Control Subtests Sensory Profile (developed by Winnie Dunn, Ph.D., OTR) The Beery-Buktenica Developmental Test of Visual-Motor Integration Developmental and Sensory History (parent questionnaire) th Developmental Test of Visual-Motor Integration, 4 Revision (VMI), by Beery and Buktenica Southern California Test of Post-Rotary Nystagmus Consultative trial with sensory motor strategies Classroom Checklist for Occupational Therapy Referral or Evaluation Review of Records -4- Wold Sentence Copying Test Clinical Observations of Sensory Integrative Function (developed by Jean Ayres, Ph.D.) Coordination, Upper-Limb Coordination, Visual-Motor Control and Upper-Limb Speed & Dexterity Sub-tests) Classroom Checklist for Occupational Therapy Referral Checklist for Occupational Therapy Evaluation of SchoolAge Children Pediatric Evaluation of Disability Inventory (PEDI), interview with parents and personal care attendant Non-standardized assessment of oral motor and feeding skill Miller Assessment for Preschoolers (MAP) Teacher Checklist for Occupational Therapy Referral Observations of Performance in Gross Motor Activities Interview of Family Members Developmental and Sensory History Adults and Adolescents (Caregiver/Parent Questionnaire) Non-standardized Assessment of Hand Function The Social Communication Skills Rating Scale (SelfAssessment) Test of Auditory-Perceptual Skills—Revised (TAPS-R by M. F. Gardner) -5- Developmental and Sensory History Adults and Adolescents This history appears to be quite long. However, many of the questions require only “check off” responses that can be completed quickly. The information you are providing is extremely useful in gaining a clear understanding of your strengths and concerns. We truly appreciate the time you are taking to complete it! General Information Name: (first) Address: (last) Date you completed this form: Date of Birth: (nickname) / / Phone Number(s): E-mail/Alternative Number: Phone Number: (relationship) (phone) Most Convenient Place and Number for you to be reached: Occupation: Person to contact in an emergency: (name) Highest Education Completed:_________________________________________________________________________ Referred by: (name) Physician: (name) (address) (phone) Would you like this physician to receive a copy of the evaluation? Medical Diagnosis (if any): Known/Suspected Allergies: Have you had allergy testing? Medical History: If you have had any of the following please describe and give approximate dates: Major illnesses: Congenital Abnormalities: Serious injury: Ear infections: Tubes in ears: Seizures: Stomach or Bowel Problems (such as frequent diarrhea, soft stools or stomach aches): Small uncontrolled movements in face or body (Tics): History of Strep infections: Exposure to lead (live in old home or eat strange items): Other: List any medications you are currently receiving, along with frequency and dosages: Purpose and effect of medication: Are there any medical precautions I should be aware of when working with you? (address) (profession) 4066 SHELBURNE ROAD SUITE 8 SHELBURNE, VERMONT 05482 802.985.8211 FAX 802.985.8733 WWW.PHILOCENTER.ORG The Philo Center Other Evaluations Received Physical Therapy Occupational Therapy Speech/Language Pathology Behavioral Specialist Psychiatry Psychology Special Education/Cognitive Neurology Hearing Vision Other **Please enclose a copy of evaluation(s) Date Name of Evaluator Location of Evaluation Dates/Frequency of Past or Current Services Childhood Developmental History The following questions are about your birth and childhood history. While you may not have access to much of this information, please answer whatever questions you have knowledge of. Childbirth - Were you a: full term baby? breech (feet first)? require intensive-care hospitalization? Yes Yes No If premature, number of weeks: Yes No No How long? As a child, did you: have feeding problems (such as trouble using bottle, learning to use spoon, or drink from cup)? Yes No If yes, describe: Yes No If yes, describe: have sleeping problems? Developmental Milestones Mark as late [L] early [E], or average [A] if known, and comment on anything unusual. Say words Crawl Roll Chew solid foods Walk Sit alone Say sentences Drink from a cup Comments: Did you have trouble learning bowel and bladder control? Yes No Cognitive/Attentional Skills Do/did you have difficulty in any of the following? (Check those that apply) Reading Math Spelling Handwriting Other Gym class Following directions Finishing tasks After-school sports Remembering information Paying attention Organizing work Restlessness Do/Did you ever receive any special education services? Yes No If yes, describe: Handedness: right left mixed dominance Page 2 The Philo Center Sensory History Please check ( ) the appropriate area. Comment as desired and cross out any parts of questions that do not fit your child. Visual-Spatial Processing - Do/Did You: Avoid or have difficulty with eye contact? See Double? Have difficulty looking for items on a grocery shelf? Communication and Auditory Processing - Do/Did You: Have speech or articulation difficulties? Have trouble finding the language to express what you want? Movement - Do/Did You: Become carsick easily? Rock in seat? Have difficulty if not in the front seat while riding in a car? Have difficulty learning to ride a bike? Hesitate or avoid climbing on ladders? Get lost easily? Taste and Smell - Do/Did You: Seem very sensitive to some smells (such as perfume, foods)? Have a limited diet? Find it uncomfortable to eat at restaurants? Tend to explore with smell; deliberately smell objects? Eat foods that are: Sweet? Sour? Salty? Spicy? Bitter (such as coffee)? Touch - Do/Did You: Become very angry/annoyed when bumped or touched unexpectedly? Dislike going barefoot? Social - Do/Did You: Make friends easily? Tend to prefer to be alone? Have a strong desire for sameness and routine? Seem discouraged or depressed? Seem sensitive to criticism? Lack self-confidence? Have trouble demonstrating emotions? Have strong outbursts of anger? Have trouble getting along with others? Tend to be aggressive? Tend to be quiet and withdrawn? Tend to be impulsive or careless? Tend to be intense or easily frustrated? Page 3 Often Sometimes Rarely/N ever Often Sometimes Rarely/ Never Often Sometimes Rarely/N ever Often Sometimes Rarely/ Never Often Sometimes Rarely/N ever Often Sometimes Rarely/N ever Comments Comments Comments Comments Comments Comments The Philo Center Have panic attacks? Tend to be very set in your routines? Have fears of leaving your home on a daily basis? Take a long time to warm up to new people and situations? Seem too serious? Have fears that interfere with daily routines? Fluctuate from happy to sad or mad quickly with little apparent cause? Motor Skills - Do/Did You: Bump into things frequently? Seem shaky when doing fine motor tasks? Tend to break many objects? Tend to drop things easily? Think of yourself as clumsy? Find physical activity helpful when overloaded or irritated? Tire easily with physical activity? Tend to move in and out of the chair while eating or doing work? Prefer to stand while working? Slump while sitting? Keep your mouth open most of the time or chew with your mouth open? Tire easily when writing? Have difficulty with tasks that have several steps? Have poor handwriting? Avoid fine motor activities? Feel reluctant to participate in or dislike sports or games? Tend to be slow in dressing? Do you have specific fears? Yes No If yes, please describe: Often Sometimes Rarely/ Never Comments Are you concerned you may have medical/psychological problems? Yes No If yes, please describe: General State of Arousal Please share your thoughts on each of the following as they pertain to you: Activity level: Attention span: What do you do to help yourself pay attention? Stress level: What do you do to help yourself calm down? Body temperature regulation (for example, overheat easily): Page 4 The Philo Center Sleep Patterns Do you: have regular sleep patterns? wake frequently during the night? tend to be an early riser, up and on the go? have difficulty falling asleep? What kinds of things do you do to help yourself wake up? What kinds of things do you do to help yourself fall asleep? Yes Yes Yes Yes No No No No If no, describe: If yes, describe: Hobbies/Pastimes Do you have any hobbies? What are your favorite pastimes? What activities do you least enjoy? Yes No If yes, please describe: Performance Can you: (some questions apply only to one sex) Use a razor for shaving? Use dental floss? Ride a bicycle? Jump rope? Skip with both feet? Rollerblade or ice skate fluidly? Snow ski? Do jigsaw puzzles? Cut with scissors? Tie shoelaces? Wrap a present? Cut with a knife? Operate a can opener (manual/electric)? Type on a computer? Use a cordless or touch-tone phone? Swim using the crawl or other strokes with coordinated breathing? Brush/Style your hair? Blow dry hair? Blow nose? Yes No Fair Average Good What do you hope to gain from this evaluation and/or treatment? What methods do you find most helpful to learn new tasks? Page 5 The Philo Center How have difficulties you are experiencing in any of the above areas affected your life? Are there any particular skills you would like to be able to achieve? Do you or anyone else in your family have similar difficulties? If so, please describe below and/or mark pertinent section of the questionnaire in a second color. Family History Is there any family history of: Left hand preference or ambidexterity? Learning problems? Behavior problems? Neurological or “nervous” disease (seizures, fits, weakness)? Medical disease such as diabetes, thyroid, heart, etc.? Mental illness such as schizophrenia, manicdepressive episodes, depression, etc.? Excessive use of drugs or alcohol? Trouble holding a job? Yes No Relationship Problem/Disorder Additional Comments Please feel free to add any information you feel would assist me in getting to know and understand you, especially your strengths and methods for coping. Thank you again for taking the time to complete this form!!! Page 6