Child's Name______________________________ Parents' Names__________________________________________

Address_______________________________________________________________________________________

City, State _____________________________________________ Zip _____________________________________

Phone __________________________email or FAX_____________________________cell_____________________

Previous Diagnosis ________________________________ given by_______________________________________

Date of Birth ___________ Male _______ Female ________ Other__________

Was this a normal pregnancy and delivery? (if NO, explain) _______________________________

Is the child currently on any medications? _______ If yes, which? ___________________________________________

Did the child have ear or respiratory infections in infancy?______ How often?__________________________________

Has the child had any of the following tests? ____ auditory brain stem response ____ hearing ____ MRI or PET ____ amino acid screen

____ IgE allergy test ____ parasite screen ____ EEG (brain) ____ X ray ____ genetic screen

 LANGUAGE

Yes No     Yes No
    Child has not yet babbled using noises or vowel sounds Child sometimes uses incorrect word order or changes the meaning intended    
    Child has not yet imitated single words spontaneously Child sometimes uses Bushisms    
    Child is not yet using single words spontaneously Child sometimes pantomimes when they can't find a word    
    Child is not yet combining two words spontaneously Child has difficulty making sense when recounting an event    
    Child is not yet using simple sentences spontaneously Child has difficulty using verb tenses correctly    
    Child is not yet using sentences (4-5 words) spontaneously Child has difficulty using spatial markers (on, over, through)    
    Child uses jargon (babbling) Child has difficulty understanding choices    
    Child sometimes uses pauses in place of words Child repeats something over and over again    

 

VESTIBULAR FUNCTIONS

Yes No     Yes No
    Child appears clumsy or topples without cause Child frequently flicks their fingers or tap their palms    
    Child has a rocking gait Child objects to tags at back of neck on clothing    
    Child steps on rather than over objects Child takes clothes or shoes off constantly    
    Child tends to touch a wall, railing, etc, when walking Child becomes dizzy when watching movement or when walking    
    Child tends to look down when walking Child does not get dizzy after spinning    
    Child has difficulty following a moving object Child is aversive to touch on the mouth or face (and was never intubated)    
    Child gets car sick Child tends to stand rather than sit to eat    
    Child averts their eyes to the side when walking down a hall Child is obsessive about swinging, spinning, or bouncing    
    Chld seeks out spinning, pounding, or jumping Child frequently makes high pitched noises    
    Child frequently tries to get upside down Child shakes head from side to side frequently    
    Child loves to climb to high places and jump off Child walks or paces in circles    
    Child slams into furniture or people Child sits on knees or keeps their feet on chair seats    
    Child bites others WITHOUT provocation Child grinds teeth    
    Child toe walks Child taps on their chin    

AUDITORY FUNCTIONS

Yes No     Yes No
    Child often seems deaf or unresponsive to sound Child frequently mutters or makes noises    
    Child often ignores their name Child is frightened or pained by some sounds    
    Child often doesn't understand what is said Child uses high pitched voice inappropriately    
    Child seems inattentive Child tends to drop consonants    
    Child has difficulty understanding colloquial expressions Child makes articulation errors beyond what is appropriate for age    
    Child often says "huh"? Child has a nasal tone    
    Child has difficulty with reading comprehension Child has difficulty learning to decode words    

 

 

 

ORAL MOTOR FUNCTIONS

Yes No     Yes No
    Child has an aversion to certain food textures Child has difficulty licking an ice cream cone or lollipop    
    Child often chokes or has swallowing problems Child kisses without puckering lips (over 3 yrs)    
    Child did not mouth objects as an infant Child has difficulty sucking a thick liquid from a straw    
    Child has difficulty chewing Child stuffs mouth too full when eating    
    Child is aversive to someone touching their face or mouth Child has difficulty imitating facial expressions    
    Child has difficulty blowing or sucking Child often drools    
 

COGNITIVE FUNCTIONS

Yes No     Yes No
    Child ignores or does not explore new things in their environment Child does not create scripts in doll or role play (and is at least 3 years old)    
    Child's play is repetitive and lacks variety Child prefers fact books to story books    
    Child explores new toys by licking, tasting, or smelling (over 3 yrs) Child's language decreases significantly when there is a play partners    
    Child usually does not ask for help or information when needed Child seems afraid of or startled by some common objects    
    Child screams frequently Child sniffs or licks people or objects when stressed    
    Child objects if a things are changed or moved Child often prefers to be alone or avoids peers    
    Child insists on watching the same video many times in a row Child often does not turn to or look at the person speaking to them    
    Child seems interested in the sensory features of a video not the story Child often does not look at person to whom they are speaking    
    Child does not often play with action figures or dolls (over 3 yrs old) Child averts eyes to the side when a face approaches (gaze aversion)    
    Child covers their ears when expecting a surprise or startling event Child tends to wander    
    Child seems stuck on a certain type of activity Child ignores a play partner or objects to a play partner    
    Child refuses to take turns (and is over three years old) Child does not play board games (and is at least 5 years old)    

 

 

 

 

MOTOR FUNCTIONS

Yes No     Yes No
    Child can NOT roll over in both directions Child has difficulty throwing a ball (and is at least three)    
    Child can NOT hold head independently Child has difficulty swinging    
    Child can NOT sit independently Child seems floppy or weak or seemed so as an infant    
    Child holds arms at waist or shoulder height when walking Child's muscles seem rigid or seemed so as an infant    
    Child can NOT pick up objects with a palmar grasp Child has a weak grip    
    Child can NOT pick up objects with a pincer grasp Child has difficulty balancing on an uneven or moving surface    
    Child does NOT reach across midline for an object Child can not jump with both feet (and is at least 3 years ld)    
    Child looks like they might fall when they run Child climbs or descends stairs without alternating feet    
    Child appears clumsy or topples without cause Child's foot turns in when walking    
    Child has difficulty grasping a pencil or crayon Child has difficulty climbing up and over a ladder    
    Child has difficulty catching a ball (and is at least three) Child has difficulty riding or had great difficulty learning to ride a tricycle    

 

NEUROLOGICAL, IMMUNE, and METABOLIC FUNCTIONS

Yes No     Yes No
    Child has frequent rashes Child has frequent headaches    
    Child is frequently congested Child has had difficulty gaining weight    
    Child has frequent diarrhea Child has an aversion to drinking water    
    Child has frequent constipation Child has been treated for a metabolic disease    
    Child has frequent stomach aches Child has had adenoids or tonsils removed    
    Child is lethargic or hyperactive Child has frequent infections    
    Child is short for age Child has been treated for allergies or asthma    

 

 

 

 

VISUAL FUNCTIONS 

Yes No      Yes No
    Child often looks at objects out of the corners of eyes Child seems obsessive about looking at certain colors or patterns    
    Child gazes at bright lights Child acts blind at times    
    Child will only look at a video briefly  Child's eyes jump when following an object move    
    Child gazes at moving horizontal lines (e.g.film credits) Child has difficulty reading or has headaches when reading    
     Child does not look directly at objects Child ignores distant objects    
    Child holds objects close to the eyes Child places face in same plane as book when reading    
     Child blinks excessively Child likes to stare at small strings or bits of dust    
     Child's eyes seem to cross or diverge Child has one eye that often diverges or wanders    

 

PREFRONTAL FUNCTIONS

Yes No     Yes No
    Child has difficulty learning a NEW dance or motor sequence Child has difficulty sustaining attention on a task    
    Child has difficulty controlling aggressions Child has difficulty seeing patterns and relationships    
    Child has difficulty recognizing or using facial expressions Child has difficulty understanding expressions of speech    
    Child has difficulty remembering faces Child has difficulty with organization    
    Child has difficulty remembering rules of behavior or complex rules in a game Child often looks at something other than what they are talking about