Client Profile Form

NEW CLIENT PROFILE

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*Referred by:

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*Mother's age at birth of child:

*Father's age at birth of child:

Prolonged labor Length: Full term  
Medication during labor Medications: Premature Weeks early:
Vaginal birth   Parent's length of stay in hospital Days:
Cesarean birth (emergency) Due to: Baby's weight LBS | OZ:
Cesarean birth (planned)   Baby's APGAR scores if known Score:

Jaundice   Intubation How long?
Transfusion Reason: Retinotherapy (ROP)  
Hemmorrhage (IVH) Grade: Breathing difficulty  
Feeding difficulties: Describe: Baby's length of stay at hospital Days:
    Other Describe:

*Check behaviors which describe your child as an infant: (only one is obligatory)

Cried a lot, fussy irritable Liked being held Resisted being held Irregular sleep patterns
Non-demanding Tense when held Very active Happy/content
Alert Floppy when held Quiet or passive Drooled excessively
Other

*Give ages as near as possible when your child: (if not applicable, write "N/A")

Bottle: how long? * Crawled? * Spoke simple words: *
Breast: how long? * Cruised: * Spoke in sentences: *
Rolled over: * Walked: * Potty trained: *
Sat unsupported: *

Allergies
Anemia
Chicken Pox
Diabetes
Ear Infections
Epilepsy/Seizures
Hearing Testing
Heart Trouble
High Temperatures
Measles
Meningitis
Mumps
Scarlet Fever
Vision Testing
Whooping Cough
Surgeries
Physical Injuries
None

Adaptive stroller Supplemental oxygen Gait trainer
Adaptive toilet chair Wheelchair Arm/hand braces
Apnea monitor Adaptive bath chair Leg/foot braces
Heart monitor Stander PECS
Tube fed Walker Communication device
Adaptive chair (describe)  

Applied Behavioral Analysis
Discrete Trials (DTT)
Early intervention school
Feeding therapy
Floortime
Hippotherapy
Infant stimulation teacher
Mobility specialist
Occupational therapy
Physical therapy
Speech therapy
Therapeutic horse riding
Vision specialist
Other
None    

*What aspect(s) of the day or daily routine is (are) the most difficult for your child? Why?

*What strategies do you find effective for calming your child when he/she becomes upset?

*Describe how your child transitions between new and familiar people?

*Describe how your child transitions between new and familiar environments?

*Describe your child’s leisure activities:

List what your child usually does during these hours?

Teacher: School:
Grade level: Type of Classroom:
1:1 instructional assistant Resource assistant

Relationship with teacher:

Relationship with classmates:

Area of academic difficulty:

Area of most success or enjoyment:

Safety and independence in accessing the school environment:


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