The Sensory Gym 4C/28 Laurence Street Hobartville

The Sensory Gym 4C/28 Laurence Street Hobartville
The Sensory Gym
4C/28 Laurence Street
Hobartville NSW 2753
02 4578 9799
REFERRAL QUESTIONNAIRE
CONTACT INFORMATION
Child’s Name:
Sex:
Date of Birth:
Age:
Parent(s) Name(s):
Address:
City:
State:
Post Code:
Email:
Home Phone:
Work Phone:
Do you have a Medicare
plan?
Do you have a private
health fund?
School Attending:
If so, which one?
Teacher’s Name:
Mobile Phone:
If so, who is your provider?
Year/Level:
School Phone:
GENERAL INFORMATION
Were there any
NO
YES. Please comment.
complications,
illnesses, or stress
during pregnancy?
Were there any
NO
YES. Please comment.
complications during
labour or delivery?
Please specify the
Vaginal Forceps Vacuum CPremature Past
conditions of your
section
due
child’s birth.
date
Indicate all that
apply.
What was your
child’s birth weight?
What were your
At 1 minute:
At 5 minutes:
child’s Apgar scores?
1
Fullterm
DEVELOPMENTAL HISTORY
Belly
Please note the Sitting
Crawling Cruising
crawling
approximate
age when your
Hopping Jumping Skipping
Running
child achieved
the following
skills.
If your child has
a medical
diagnosis,
please specify.
Does your child NO
YES
have a history
How many?
of ear
At what ages?
infections?
How were they treated?
Does your child NO
YES. Please comment.
currently take
any
medications?
Does your child NO
YES. Please comment.
have any
allergies?
Has your child
NO
YES. Please comment.
Walking
First
words
Talking
Riding a
tricycle
Riding a
2-wheel
bike
Skipping
rope
experienced any
major injuries or
hospitalisations?
Does your child
have a history
of seizures?
Does your child
wear glasses?
Has your child
received
occupational
therapy
services in the
past?
Has/does your
child receive
other
interventions?
Indicate all that
apply.
2
NO
YES. Please comment.
NO
YES. What are the glasses meant to correct?
NO
YES
At what age did your child begin therapy?
How long did/has your child receive(d) therapy?
How frequently was/is your child seen for therapy?
NO
YES
Speech
therapy
Physiotherapy
Applied
Behavioural
Analysis
(ABA)
How
long?
How long?
How long? How long? How
long?
DIR/
Floortime
Others:
_______
What are your
primary
concerns?
What is/are the
hardest time(s)
of the day and
how do these
times impact
on your family?
SLEEPING
What activities
do you use as
part of your
child’s bedtime
routine?
Indicate all that
apply.
Please describe
any necessary
specifics
regarding your
child’s bedtime
routine.
What happens
if this routine is
disrupted?
What time is
your child put
to bed?
What time does
your child fall
asleep?
Where does
your child fall
asleep?
Does your child
have difficulty
with sleeping?
How many
times per night
does your child
waken?
3
Bath
time
Singing/
Humming
Reading
Cuddling
Bouncing
Massage
Rocking
Others:
Impact on child:
Impact on family members:
NO
Almost
never
YES
Do family members have interrupted
sleep as a result?
1-2
3-4
5-6
NO
YES
7+
Screams
Plays with
Goes to
What does your Whimper
toys
parents’
child do when
bedroom
he/she
awakens?
What activities Feeding Singing Humming Cuddling Rocking
do you use to
get your child
back to sleep?
Indicate all that
apply.
Describe any
routines that
are helpful for
getting your
child back to
sleep.
How old was
your child when
he/she
consistently
slept through
the night?
Does your child NO
YES
seem to require
too much or
How many hours nightly?
too little sleep
or sleep at odd
What times of day?
times?
Does your child NO
YES
take naps?
Frequency of naps?
Duration of naps?
Location of naps?
Does your child need help to fall
asleep for nap?
What time does
your child
awaken?
What mood is
your child in
upon
awakening in
the morning?
4
Puts self back
to sleep
Bouncing
NO
Massage
Others:
Others:
YES
FEEDING
Was your child NO
breast fed as an
infant?
YES. For how long?
If child was
bottle fed as an
infant, were
there any
difficulties or
concerns?
Did your child
have a strong
suck as an
infant?
Did your child
frequently spit
up as an infant
or have reflux?
Did your child
have problems
with appetite
or weight gain
as an infant?
Did your child
respiratory
problems as an
infant?
Does your child
avoid/limit
food based on
the following
characteristics?
Indicate all that
apply.
NO
YES. Please comment.
NO
YES
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES
Does your child
show strong
preferences for
food based on
the following
characteristics?
Indicate all that
apply.
NO
5
Variety
of food
selection
Temperature
Food
texture
Crunchy
foods
Chewy
foods
Food
colour
Mixed
food
textures
Please comment.
YES
Variety
of food
selection
Tempera
ture
Please comment.
Food
texture
Crunchy
foods
Chewy
foods
Food
colour
Mixed
food
textures
Does your child NO
have difficulty
with ingesting
foods? Indicate
all that apply.
YES
Is there a
disruption in
family
mealtime as a
result of
atypical eating
patterns?
Does your child
exhibit oral
motor
sensitivities or
seeking?
Indicate all that
apply.
NO
YES. Please comment.
NO
YES
Does your child
attempt to eat
unusual,
noxious, or
inedible
substances or
place in
mouth?
How long does
your child sit at
mealtime?
NO
Examines
Gags/vomits
objects by
frequently
placing in
mouth
YES. Please comment.
Where does
your child eat
meals?
Please comment.
Chewing variety of
foods
Please comment.
Swallowing a
variety of foods
Bites/chews
objects or
clothing
frequently
Grinds teeth
1-2 minutes
3-5 minutes
6-10 minutes
Entire meal
Does this impact on the quantity of food ingested?
NO
YES
How does this impact harmony at mealtimes? Please comment.
What routines do Please comment.
you follow that
are helpful for
getting your child
to eat meals?
6
Sucking through a
straw
What happens if
this routine is
disrupted?
Impact on child:
Impact on family members:
GROOMING
Does your child
have difficulty
with grooming
activities?
Indicate all that
apply.
Does your child
avoid grooming
devices?
Indicate all that
apply.
What routines do
you follow that
are helpful for
getting your child
to participate in
grooming
activities?
What happens if
this routine is
disrupted?
Tooth
brushing
Bathing
Hair
brushing/
combing
Face
washing
Haircuts
Nail
trimming
Blowing
nose
Please comment:
Electric
Barber’s
toothbrushes clippers
Please comment:
Nail clippers
Dentistry
tools
Others:
Please comment:
Impact on child:
Impact on family members:
DRESSING
Which clothing is
your child able to
take off
independently?
Indicate all that
apply.
Which clothing is
your child able to
put on
independently?
Indicate all that
apply.
7
Shirt
Pants
Underwear
Shoes
Sock
Coat
Shirt
Pants
Underwear
Shoes
Sock
Coat
Which fasteners
can your child
manage
independently?
Indicate all that
apply.
Is your child
selective in the
types of clothing
textures he/she
will wear?
Snaps
Does your child
prefer to wear
minimal clothes,
regardless of
weather?
Does your child
prefer clothing to
cover entire
body or dress in
layers, regardless
of the weather?
Does your child
frequently adjust
clothing, as if
uncomfortable?
Do tags in
clothing or
seams in socks
bother your
child?
What routines do
you follow that
are helpful for
getting your child
to participate
with dressing?
What happens if
this routine is
disrupted?
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES
NO
Zippers
YES
What types of clothing textures are preferred?
What clothing textures are avoided?
What type of behaviour/reaction is seen?
Specify.
Impact on child:
Impact on family members:
TOILET TRAINING
Is your child
currently toilet
trained for
bladder?
8
Buttons
(unbutton &
button)
NO
YES
At what age?
Ties shoes
Was it a struggle
learning to tie?
NO
YES
Is your child
currently toilet
trained for
bowel?
NO
YES
Does your child
experience
urinary/bowel
issues? Indicate
all that apply.
Incontinence
during the
day
How often?
At what age?
Bedwetting
Constipation
Loose stools
Lack of
awareness
How often?
How often?
How often?
How often?
Does your child
NO
YES
wear a nappy or
pull-up at night?
What routines do Specify:
you follow that
are helpful for
getting your child
to participate in
toileting?
What happens if
Impact on child:
this routine is
Impact on family members:
disrupted?
SOCIAL FUNCTION/FAMILY LIVING
Are you limited in NO
YES. Please comment.
attending
family/social
gatherings
because of your
child’s
behaviour/
reactivity to
events?
Is your child
unable to attend
birthday parties?
NO
YES. Please comment.
Are you unable
to leave your
child alone with
familiar, but not
routine,
caregivers for
child care?
NO
YES. Please comment.
Is your family
unable to
maintain
relationships
with other
families?
NO
YES. Please comment.
9
Is your family
unable to pursue
hobbies and
interests?
NO
What routines do
you follow that
are helpful for
getting your child
to participate in
social situations?
What happens if
this routine is
disrupted?
Specify.
COMMUNITY
Is your child
unable to eat out
at restaurants?
YES. Please comment.
Impact on child:
Impact on family members:
NO
YES. Please comment
Is your child
uncomfortable
on elevators,
escalators, or in
cars?
Does your child
avoid busy,
unpredictable
environments?
Does your child
have an
excessive
reaction to light
touch sensation?
Is your child
unresponsive to
being touched or
bumped?
Does your child
have an
excessive
reaction if
bumped
unexpectedly?
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES
Does your child
exhibit a lack of
safety
awareness?
10
What type of reaction/behaviour is seen?
NO
YES
NO
YES. Please comment.
NO
YES. Please comment.
Does your child
have difficulty
travelling on a
variety of public
transportation?
Does your child
have difficulty
flying on planes?
NO
YES. Please comment.
NO
YES. Please comment.
Is your child
unable to attend
sleepovers?
NO
YES. Please comment.
Does your child
have difficulty
with loud,
crowded sporting
events?
Does your child
have difficulty
sitting through
public
performances?
Does your child
have difficulty in
the grocery
store?
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
Does your child
have difficulty
with long car
rides?
NO
YES. Please comment.
Does your child
have trouble
standing in a
queue?
NO
YES. Please comment.
SOCIAL INTERACTION
Does your child
exhibit
aggressive
behaviour?
NO
What types of
behaviours are
exhibited?
Biting
11
YES
Is it directed towards NO
him/herself?
Is it directed towards NO
others?
Pinching
Kicking
YES
YES
Hitting
Others:
Does your child
exhibit
tantrums?
NO
YES
How frequently do they occur?
What triggers tantrums?
On average, how long does a tantrum last?
Describe strategies that are effective for helping your child calm
during a tantrum.
Is your child
easily frustrated,
anxious or
overwhelmed?
Is your child
overly
dependent on
parent(s) or
clingy?
Does your child
easily escalate
from whimper to
intense cry?
If your child uses
atypical,
repetitive
behaviours,
which
behaviours are
demonstrated?
(Indicate all that
apply.)
NO
Are tantrums a source of distress to
other members of the family?
YES. Please comment.
NO
YES
Does your child
struggle with
transitions
between
activities?
12
Are separations challenging?
NO
YES
NO
YES
NO
YES. Please comment.
Hand
flapping
Rocking
Head banging
Jumping
Smelling
Breath
holding
Humming
Self-talk
Biting
Mouthing
objects
Visual
fixing
Spinning
Teeth
grinding
Others:
NO
YES
How long does it take to transition, on average?
What transitions are difficult?
Please comment.
What strategies are used to help
transitions?
Please comment.
Does difficulty transitioning cause
distress to other family members?
NO
YES
Please comment.
Does your child
struggle when
there is excessive
auditory input in
his/her
environment?
Does your child
struggle around
individual with
certain voice
pitches?
Does your child
struggle to
communicate
own needs?
What is your
child’s primary
form of
communication?
How often does
your child make
eye contact
during
conversation?
How often does
your child orient
to his/her name
being called?
Does your child
have difficulty
separating from
parent or
caregiver?
Does your child
appear to have
an awareness of
others?
Does your child
appear to have
an awareness of
self?
Does your child
lack fear of
strangers?
NO
How does your
child react in
new/unfamiliar
situations?
Please comment.
13
YES
How does your child react?
NO
YES. Please comment.
NO
YES. Please comment.
Talking
Signing
Sounds/
vocalisations
Pointing/
gesturing
Crying/
screaming
Less than
25% of the
time
25% of the
time
50% of the
time
75% of the
time
100% of the
time
Less than
25% of the
time
25% of the
time
50% of the
time
75% of the
time
100% of the
time
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
Does your child
have difficulty
paying attention
in noisy
environments?
Does your child
regularly avoid
initiation of
social
interaction?
Does your child
avoid
maintaining
social
interaction?
Does your child
experience
difficulties with
language
expression?
(Indicate all that
apply.)
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES
Easily
frustrated,
anxious or
overwhelmed
Flat,
monotonous
voice
Frequently
mispronounces
words (i.e.
bisghetti)
Hesitant
speech
Poor
articulation,
difficult to
understand
Tendency to
stutter
Difficulty
making choices
10-30
minutes
30+ minutes
Difficulty
expressing
emotions
verbally
What routines
Specify.
do you follow
that are helpful
for getting your
child to socialise?
What happens if Impact on child:
this routine is
disrupted?
Impact on others:
PLAY SKILLS/PEER INTERACTION
Is your child
destructive
toward toys?
Does your child
struggle to play
alone (excluding
TV watching)?
How long is your
child able to play
alone?
What are your
child’s preferred
play activities?
14
NO
YES. Please comment.
NO
YES. Please comment.
1-2 minutes
Please specify.
2-5 minutes
5-10 minutes
How much time
per day is spent
in the following
activities?
Does your child
struggle playing
with other
children?
(Indicate all that
apply.)
Passive activities (i.e. TV,
computer)
NO
YES
Is your child
preoccupied with
seeking intense
movement
during play?
(Indicate all that
apply.)
Does your child
have a strong
desire for
structure or
control?
Does your child
struggle to play
in familiar
settings?
Does your child
struggle to play
in unfamiliar
settings?
Which
playground
equipment will
your child play
on? (Indicate all
that apply.)
Which
playground
equipment does
your child avoid?
(Indicate all that
apply.)
Does your child
avoid certain
types of toys (i.e.
textured toys)?
NO
Parallel
play –
playing
alongside
other
children
YES
15
Spinning
Movement activities (i.e.
playground, roughhouse
play, sports)
Interactive
play –
playing
with other
children
Bouncing
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
Structured
group play
Crashing
Learning/interactive
activities
Making
friends
Jumping
Rocking
Pretend
play
Others:
Swings
Monkey
bars
Crawl
tunnels
Vertical
climbers
Merry-goround
Ladders
Slide
Climbing
wall
Bridges
Teeter
totter
Spring
riders
Others:
Swings
Monkey
bars
Crawl
tunnels
Vertical
climbers
Merry-goround
Ladders
Slide
Climbing
wall
Bridges
Teeter
totter
Spring
riders
Others:
NO
YES. Please comment.
Does your child
exhibit poor
safety awareness
of engage in
activities that are
potentially
dangerous (i.e.
jumping without
regard)?
Does your child
avoid any of the
following
“messy”
activities?
(Indicate all that
apply.)
Which surfaces
does your child
have difficulty
with? (Indicate
all that apply.)
Does your child
have poor depth
perception (i.e.
ducks or blinks
when ball is
thrown to
him/her,
difficulty with
stairs)?
Is your child
unable to pull up
on the monkey
bars with bent
arms and legs?
Is your child
unable to
maintain bent
arms and legs
while moving bar
to bar on the
monkey bars?
Which gross
motor skills does
your child have
difficulty with in
comparison to
same age peers?
16
NO
Sand
YES. Please comment.
Playing in
the grass
Ascending
stairs
Descending
stairs
NO
YES
NO
YES
NO
YES
Hopping
Finger
paint
Grass
Jumping
Play-doh
Gravel
driveways
Skipping
Glue
Woodchips
Running
Sand
Others:
Others:
Riding a
tricycle or
bicycle
SCHOOL SKILLS
Where does your
child attend preschool or school?
Home
school
Does your child
exhibit a hand
preference?
NO
Daycare
Special
needs
pre-school
class
Regular
education
class
Special
education
class
Other:
YES
Right
Left
Established at what age?
Does your child
frequently
change his/her
grasp on
pencils/other
tools?
Which writing
skills does your
child struggle
with/avoid?
(Indicate all that
apply.)
NO
YES. Please comment.
Drawing/
Colouring
Tracing
Copying
Handwriting
Use of graded
pressure
Stabilisation of
paper while
drawing/writing
Proper desk
posture
Others:
Too
much
Too
little
Which fine motor
skills does your
child struggle
with/avoid?
(Indicate all that
apply.)
Which skills does
your child
struggle with?
(Indicate all that
apply.)
Grasping and manoeuvring scissors
Performing 2 different tasks at the
same time (i.e. hold and turn paper
while cutting, cut food using knife and
fork)
Finding items
within a hidden
picture
Phonetic learning
Telling time
Puzzles and
construction/
manipulation of
materials
Spelling
Is your child’s
draw-a-person
immature for
age?
Does your child
write up/down
hill on paper?
NO
YES. Please comment.
NO
YES. Please comment.
17
Responding
promptly to
verbal instruction
Sequencing
months of
year
the
Writing numbers
& letters correctly
(without frequent
reversals)
Which of the
following visualrelated skills
does your child
struggle with?
(Indicate all that
apply.)
Poor eye
teaming
Using
peripheral
more than
central vision
Keeping eyes
too close to
work
Copying from
board to
paper
Short
attention
span in
reading/
copying
Reverses
letters or
words
Turning head
when reading
across a page
Reading
comprehension
Does your child
have difficulty
sitting still?
NO
Rereads or
skips words
when reading
Closing/
covering one
eye while
doing near
work
Losing place
often during
reading
Doesn’t look
when
manipulating
objects
Eye strain
after reading
a short period
of time
Needing
finger or
marker to
keep place
while reading
Tracking a
moving object
with head
movement
YES
Does your child fidget while
listening?
NO
YES
MOVEMENT SKILLS
Does your child
become overly
excited after
movement
activity?
Does your child
display the
following
movement
difficulties?
(Indicate all that
apply.)
NO
YES. Please comment.
Avoids activities where
feet leave the ground
Loses balance/trips
easily or frequently
Avoids/fear activities
requiring balance
Dislikes being moved
Stamps/slaps feet on
ground when walking
Drags feet or has poor
heel-toe pattern when
walking
Resists having head tiled
backwards
Excessive dizziness from
swinging, spinning, or
riding in a car
Fearful of being tossed in
the air or turned upside
down
Confuses left and right
Difficulty moving from
one floor surface to
another
Poor sense of direction
or awareness of space in
relationship to self
Sets jaw or locks major
joints for stability when
applying effort
18
Avoids age-appropriate
gross motor activities
Drags hand or bangs
object along wall when
walking
Unable to walk on
alternating treads on
stairs
Fears falling when no
real danger exists
Holds head upright when
leaning or bending over
Dislikes inversion
Lethargic and inactive
Difficulty moving
between rooms
Leans on objects/people
for stability
Poor body scheme
awareness
Limited rotation of hip
and/or shoulder girdle
around central core of
body
Seems weaker or tires
more easily than peers
Moves with quick bursts
of activity rather than
with sustained effort
Poor coordination or
sense of rhythm
Does your child
NO
YES. Please comment.
like to be
wrapped tightly
in a sheet or
blanket or seek
tight spaces?
Does your child
NO
YES. Please comment.
shake head
vigorously or
assume an
upside down
position
frequently?
Is your child able NO
YES. Please comment.
to conceive and
organise a plan
of action to
direct
play/movement?
DAILY ENVIRONMENT/INTERACTION
Does your child
Vacuum
Hair dryer
Fans
demonstrate an
cleaner
irrational fear of
Toilet flushing Air vents
Lawn mower
any of the noisy
appliances or
Please comment.
machines?
(Indicate all that
apply.)
Does your child
demonstrate an
irrational fear of
any of the
following noisy
sounds?
(Indicate all that
apply.)
Jets/airplanes
Is your child
confused about
the direction of
sounds?
NO
YES. Please comment.
Does your child
hear sounds that
others do not or
before others
notice?
NO
YES. Please comment.
19
Trucks
Please comment.
Blender
Coffee grinder
Leaf blower
Others:
Thunder
Others:
Does your child
cover ears to
shut out
objectionable
auditory input or
over-react to
unexpected
sounds?
Does your child
attend to
auditory input
less than a few
seconds?
Does your child
appear under- or
oversensitive to
pain?
Does your child
dislike having
eyes covered or
being in the
dark?
Is your child
overly sensitive
to
lights/sunlight?
Does your child
seem to need to
“fix” the
environment (i.e.
arrange objects,
chairs, shut
doors)?
Does your child
avoid
environments/
objects with
certain odours?
Does your child
seek
environments/
objects with
certain odours?
SUMMARY
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
NO
YES. Please comment.
What do you
perceive as your
child’s strengths?
Please comment.
20
What are the
primary concerns
prompting this
assessment/
intervention?
Please comment.
What are your
hopes and goals
from assessment
and/or
intervention?
Please comment.
From Frick, S. (2009) Listening with the Whole Body. ©Vital Links
21
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