OT Background Information Paediatrics Form

Family Information

What family members does the child share the home with?

(If any)

Referring Information

Current Concerns

(What are your Child’s favourite toys / activities / characters / people / shows / songs / books?)
(What does your child fear, finds irritating, avoids, or resists?)

Medical History

(Wheelchairs, glasses, hearing aids, weighted blankets etc.)

Challenging Behaviour

Does your child show any of the following? (Please indicate frequency if present)

(Please describe if present)

Food Preference

(Selective eater, eats only certain foods or textures, etc.)
(Using spoon / fork, drinking through straw, food choices, ability to chew/swallow, etc.)

School History

Developmental History

Please check all the developmental milestones that your child has achieved. Please additionally note developmental timeframe.

(Walking up / down stairs, running smoothly)
(Stacking blocks, drawing, cutting, writing)

Behaviour and Social Skills

Please indicate if your child…

Daily Routine and Family Information

Describe your child’s dressing skills below

(Ability getting dressed / undressed, managing buttons / snaps / zippers, laces, etc.)

(e.g. wool, silk, tags, etc.)

Describe the level of support your child requires during hygienic activities

Describe the level of support your child requires with personal grooming

Describe the level of support your child requires with toilet hygiene

(E.g. Setting table, making lunches, making bed, packing school bag. etc.)

Describe a Typical Day

Morning Routine

(If present)

Afternoon Routine

(If present)

Nighttime Routine

(If present)