The document is an intake questionnaire for a Down Syndrome Specialty Clinic that collects information about a child's medical history, family, education, speech, nutrition, and other developmental areas. It asks for the child's name and birthdate, insurance information, primary concerns, medical providers, current diagnoses, and contact information for parents/guardians. It also inquires about speech development, genetic testing, feeding issues, therapies received, education, hearing, behavior, and fine motor skills. The goal is to evaluate the child's needs and address the parents' primary concerns.
The document is an intake questionnaire for a Down Syndrome Specialty Clinic that collects information about a child's medical history, family, education, speech, nutrition, and other developmental areas. It asks for the child's name and birthdate, insurance information, primary concerns, medical providers, current diagnoses, and contact information for parents/guardians. It also inquires about speech development, genetic testing, feeding issues, therapies received, education, hearing, behavior, and fine motor skills. The goal is to evaluate the child's needs and address the parents' primary concerns.
The document is an intake questionnaire for a Down Syndrome Specialty Clinic that collects information about a child's medical history, family, education, speech, nutrition, and other developmental areas. It asks for the child's name and birthdate, insurance information, primary concerns, medical providers, current diagnoses, and contact information for parents/guardians. It also inquires about speech development, genetic testing, feeding issues, therapies received, education, hearing, behavior, and fine motor skills. The goal is to evaluate the child's needs and address the parents' primary concerns.
The document is an intake questionnaire for a Down Syndrome Specialty Clinic that collects information about a child's medical history, family, education, speech, nutrition, and other developmental areas. It asks for the child's name and birthdate, insurance information, primary concerns, medical providers, current diagnoses, and contact information for parents/guardians. It also inquires about speech development, genetic testing, feeding issues, therapies received, education, hearing, behavior, and fine motor skills. The goal is to evaluate the child's needs and address the parents' primary concerns.
Subscriber name: ______________________________ Subscriber Date of Birth: ________________
Please tell us who lives in your home:
Name Relationship to patient Age Special medical/behavioral needs?
List any medical providers who provide care for your child (for example cardiologist, neurologist, gastroenterologist): Doctors Name Specialty Area Who referred you to our clinic? ___________________________________________________________
Was there a specific event that led to a referral to this clinic? YES / NO If YES, what? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
List any current diagnoses, other than Down syndrome, your child has (for example autism, hearing/vision problem, heart condition, ADHD, other): _____________________________________________________________________________________ _____________________________________________________________________________________
What do you hope to get from an evaluation at the Down Syndrome Specialty Clinic? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
SPEECH PATHOLOGY:
What language(s) are spoken at home? _____________________________________________________
What percent/how much does your child HEAR of each language? ________________________ What percent/how much does your child SPEAK of each language? ________________________
How many gestures does your child have (high five, clap, wave, thumbs up etc.)? € None € 1-5 € 5-20 € 20 + Does your child: • Play pretend or make-believe (FOR EXAMPLE, pretend to from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal)? YES / NO / SOMETIMES
• Make unusual finger movements near his or her eyes (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes)? YES / NO / SOMETIMES
• Point with one finger to ask for something or to get help (FOR EXAMPLE, pointing to a snack or toy that is out of reach)? YES / NO / SOMETIMES
• Show you things and share their interests with you (FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)? YES / NO / SOMETIMES
• Respond to their name (FOR EXAMPLE, does he/ she look up, talk or babble, or stop what he/ she is doing when you call his/her name)? YES / NO / SOMETIMES • If something new happens, does your child look at your face to see how you feel about it (FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face)? YES / NO / SOMETIMES
• Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her? YES / NO / SOMETIMES
• Does your child try to copy what you do (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)? YES / NO / SOMETIMES
• Name of Hospital / Clinic: _________________________________________________ • Name of physician / genetic counselor: ______________________________________
Have you met with a genetic counselor? YES / NO
If yes, list the name of the facility and genetic counselor:________________________________
Are you interested in discussing any of the following topics? Check all that apply. € Genetic causes of Down syndrome € Recurrence risks (What are the chances to have another child affected with Down syndrome?) € Health concerns and features of Down syndrome € Other_______________________________________________________________________ NUTRITION:
Do you have any concerns about your child’s growth, eating habits, food intake or meal time behavior? (Please check below) € Overweight € Underweight € Constipation € Diarrhea € Vomiting € Chewing food € Swallowing food € Gagging/choking € Refusal to eat € Getting upset at meals € Comments: _____________________________________________________________________
Does your child have a feeding tube? YES / NO
COMMUNITY RESOURCES:
Does your child receive any of the following therapies outside of school or early intervention? Therapy type Where? How often? Speech Feeding Physical Occupational List other:
Are you interested in more information about:
€ Parent / sibling support groups € Developmental Disabilities Administration (DDA) € Supplemental Security Income (SSI) € Housing € Financial support € Respite Care EDUCATION:
Current school & district (age 3 and up) OR early intervention (birth to age three) program name: _____________________________________________________________________________________ Address: _____________________________________________________________________________ City: ____________________________ State: _____________ Zip code: __________________________ Phone number: __________________________ Fax Number: __________________________________
What therapies does your child get from their school or early intervention program? Therapy type How often? Speech Feeding Occupational Physical List other:
Does your child have an Individualized Education Plan (IEP) at his/her current school program? YES / NO
Do you have concerns about your child’s IEP? YES / NO
When did your child last have their hearing checked by an audiologist? _______________ (Month/Year)
Was the last hearing test normal? YES / NO
If NO, what were the results (mild, moderate, or severe hearing loss AND type of hearing loss: conductive or sensorineural)? ____________________________________________________________
PSYCHOLOGY:
Do you have concerns about your child’s behavior? YES / NO
If yes, please let us know what your concerns are:
Please check any areas of concern regarding your child’s development.
FINE MOTOR: BEHAVIOR:
_____ Holds pencil or crayon awkwardly _____ Short attention span
_____ Has difficulty with writing _____ Tantrums frequently
_____ Awkward with manipulatives _____ Difficulty w/change in routine
(legos, game pieces, stringing small beads) _____ Has unusual repetitive behaviors _____ Has difficulty using scissors (e.g. flaps hands, toe-walks, makes noises, etc.)
_____ Difficulty handling spoon or fork _____ Poor eye contact
GROSS MOTOR: SELF-CARE:
_____ Clumsiness in walking or running _____ Dislikes some textures of clothes
_____ Seems weak; fatigues easily _____ Needs extra help w/dressing for age
_____ Avoidance or difficulty using _____ Overly sensitive to brushing teeth,
playground equipment shampoos, haircuts
_____ Fearful of heights, climbing _____ Toileting issues
_____ Picky eater
SENSORY PROCESSING: _____ Chewing/swallowing problems _____Overreacts to touch/ physical contact _____ Awkward feeding self _____ Frequent need for something in mouth
_____ Refuses certain food textures PLAY:
_____ Upset by loud noises _____ Has difficulty playing with others
_____ Seeks out movement excessively _____ Prefers to play alone
_____ Gets overwhelmed easily _____ Plays w/same toys over and over
_____ Doesn’t like hands messy _____ Hard time imitating others in play OTHER COMMENTS: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
