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Parent or
Guardian name: |
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Child name: |
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Age: |
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| Address: |
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Postcode:
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Email: |
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| Phone number (H): |
(W):
(M):
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Preschool
Kindergarden
Primary
High School
Adult School year
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| MEDICAL HISTORY |
| Has your child had any of the following?
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Middle ear infections ('glue ear')
Insertion of 'grommets'
Tonsillitis or frequent sore throats
Hearing problems
Problems with vision (e.g. blurred vision, watery eyes, bothered
by glare)
Headaches
Convulsions |
| Serious
injuries. Please specify: |
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| Other medical conditions or complaints.
Please specify: |
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| Does your child take medication?
Yes
No |
| Name(s) of medication(s):
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| Has your child had his/her hearing
tested?
Yes
No |
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| Has your child had his/her eyesight
tested?
Yes
No |
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| FAMILY HISTORY |
| Has anyone in your
child's immediate or extended family had difficulties with: |
Articulation
Language skills
Stuttering
Dyslexia
Reading or learning
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Has your child ever
received special education help
Yes
No
(e.g. special reading group, language support class)? |
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| In your opinion, what
is your child's current achievement at school in the following areas?
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apply to your child? |
Dislikes school
Blames teacher for difficulties
Complains school is boring
Refuses to cooperate with teachers
Teachers report 'discipline' problems
Is not motivated to complete class or homework activities
Frequently hands in 'sloppy' work or neglects to hand in assignments
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| Comprehension |
| Does your child have
difficulties: |
Understanding questions
Following instructions correctly
Understanding indirect requests and sarcastic comments
Following stories as a whole, drawing conclusions, making predictions
Understanding that the meaning of a word can change depending on
the context |
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| Auditory Processing |
Have difficulties saying speech sounds (e.g. 'lellow' fpr 'yellow',
'fum' for 'thumb')
Have difficulties saying words of several syllables (e.g. 'hostipal'
for 'hospital', 'puter' for 'computer')
Fail to understand rhymes
Confuse similar-sounding words (e.g. 'cone' for 'comb')
Have difficulties identifying the number of syllables or sounds
in words |
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| BEHAVIOUR |
| Please tick the
behaviours that refer to your child. |
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| Activity Level |
Cannot keep still or stay quiet; 'hyperactive', restless
Lethargic, often tired, fatigues quickly |
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| Attention |
Cannot concentrate on a task for long
Needs to be called back to task continually
Cannot ignore 'distractions'; overly aware of nearby sounds, sights
and smells |
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| Movement and Balance |
Poor balance on play equipment
Difficulties climbing or descending stairs
Seems overly sensitive to movement; becomes carsick regularly
Constantly moving; often swinging, twirling, bouncing and rocking
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| Visual Perception |
Difficulties matching colours, shapes and sizes
Difficulties completing puzzles, uses 'trial and error' to place
pieces
Reverses words, letters or number after Year One
Skips words, phrases or lines when reading
Loses place when reading or copying; needs finger or marker to keep
place
Difficulties with smooth eye-tracking (following objects with eyes)
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| Is there any other
information relevant to your child's difficulties that you would
like to tell us about? |
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| Print Form |
| Please print a copy of this form for your own records... |
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| Submission |
You can post or e-mail this form to the Cellfield Office...
To post this form send it to our Southport office address:
Cellfield Pty Ltd
Suite 2E
34 High Street
Southport QLD 4215
To e-mail this form click the "Submit" button below...
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