Case History Questionnaire All information you provide will be kept confidentiallyChild's Name* First Last Date of Birth* DD MM YYYY Age: Years*Months*Address* City State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhonePhone*Email* Who referred you to Kids First?How can we help you?*What are your major concerns for your child? How are your child's difficulties impacting your child and your family?How are your child's challenges impacting on them? (eg learning, friendships, self-esteem, family relationships, behaviour) Family Information Parent 1 Name:Parent 2 Name:Siblings: NameAgeSiblings: NameAgeSiblings: NameAgeCountry of Birth: Child*Languages spoken at home: Child*Country of Birth: Parent 1Languages spoken at home: Parent 1Country of Birth: Parent 2Languages spoken at home: Parent 2Parent / Carer Occupations : Parent 1Parent / Carer Occupations : Parent 2Household consists of: (Tick all that is relevant) Parent 1 Parent 2 Siblings Grandparents Other Preschool Nameor School NameDays attending Monday Tuesday Wednesday Thursday Friday ClassTeacher's NamePlease describe your child's difficulties as specifically as possible: (What happens? Where? How Often?)*Please describe any concerns expressed by your child's teachers, doctor or other therapists:*What activity and/or time of day is the most difficult for your child and family?*What activity and/or time of day is the easiest for your child and family?*Is there a family history of speech, language, motor coordination, sensory, attention, learning or emotional difficulties? (ADD, Anxiety, etc)*YesNoIf 'Yes', give details:Is your child aware of his/her difficulties?*YesNo Professionals involved in your child's care: General Practitioner NameLast visited LocationPaediatrician NameLast visited LocationSpeech Pathologist NameLast visited LocationOccupational Therapist NameLast visited LocationPsychologist/Social Worker NameLast visited LocationEar Nose and Throat Specialist NameLast Visited LocationAudiologist NameLast visited LocationPhysiotherapist NameLast visited LocationOther NameLast visited Location Have your child's skills been formally assessed by one of the following specialists? Audiologist Assessment Date ResultsReport Attached?YesNo Optometrist Assessment Date ResultsReport Attached?YesNo Speech Pathologist Assessment Date ResultsReport Attached?YesNo Occupational Therapist Assessment Date ResultsReport Attached?YesNo Psychologist Assessment Date ResultsReport Attached?YesNoUpload reports here Drop files here or Accepted file types: pdf, docx, png, jpg. Health and developmental milestones. Does your child have any medical conditions or a medical diagnosis?*YesNoDetailsPregnancy DurationBirth WeightIllnesses during pregnancy?Complications during birth?Baby's illnesses or special treatment in first days/weeks of life? At what age (years,months) did your child ...... ? Breast feedBegin using pencils/crayonsBottle feedSay single wordsTolerate solids for the first timeShow interest in toysDrink well from a cupJoin 2 - 3 wordsSit alone without supportStart feeding selfCrawlStart dressing selfWalk unaidedAchieve toilet training (by day)BabbleAchieve toilet training (by night)Stop using a dummy Has your child suffered from any of the following illnesses and conditions? Please provide details of frequency and when this last occurred. AllergiesAnxietyAsthmaChickenpoxColdsConvulsionsCroupDizzinessEar InfectionsEncephalitisEpilepsyGerman measlesHeadachesHigh feverInfluenzaMeaslesMeningitisMumpsPneumoniaSeizuresTonsilitisOtherHas your child suffered any illness/injuries requiring hospitalisation?*YesNoType of illness/accidentAge at which this occurredDuration of illness/Hospital stayHas there been a change in your child's speech, motor coordination or anxiety levels in the last six months?*YesNoIf yes, please describe Daily Skills Please describe your child's eating and drinking skills (e.g. what child eats, consistency of food, when child eats, how much child eats, how child eats, who feeds child, where child eats, parent involvement in eating)*Is your child a fussy eater?*YesNoFavourite foods?*Any foods not tolerated?*Please describe your child's play skills (e.g. people your child plays with, what toys your child plays with, how your child plays with the toys, sharing, etc)*Please describe your child's social interaction skills (e.g. eye contact, duration of interaction with parent and/or peer, need for routines, obsessions, sensitivities, turn-taking, awareness of danger, humour, takes things literally)*Please describe your child's comprehension of language (e.g. understanding of words, what is being said, following directions)*Please describe your child's expression of language (e.g. non-verbal communication such as gestures, words being used, how many words/sentences, how your child communicates with family members and others)*Please describe your child's speech sounds (e.g. sounds used, sounds your child has difficulty with, particular words child produces incorrectly)* Motor Coordination and Sensory Skills Please tick the boxes that apply to your child* Has difficulty with handwriting Has trouble writing on the line Does not leave spaces between words Has trouble paying attention Has trouble being organised (i.e. forgets lunch box at school, forgets to put jacket on at end of day) Seems generally clumsy (i.e. when walking or catching a ball) Has difficulty using a fork/spoon for eating Has difficulty drinking from a cup without spilling Resists self-care activities (i.e. doesn't like to have their face washed, hair cut, etc) Becomes anxious around loud/sudden noises (i.e. covers ears or cries) Has difficulty doing up buttons or zippers Has difficulty putting on shoes/socks Has difficulty tying shoe laces Has difficulty with tranisitioning from one activity to another (i.e. becomes angry or resists) Has difficulty sitting still Finds it difficult to return to a calm state after being upset or very excited/active Play and Learning How would you describe your child?* Happy Affectionate Prefers to be alone Friendly Shy Withdrawn Talkative Co-operative Nervous Hard to discipline Distractible Easy Going Aggressive Helpful Over-active Under-active A trier Fussy Playful Irritable Forgetful Thoughtful Confident Gives up easily OtherWhat are your child's favourite toys and games?*Has your child had any lengthy absences from school or preschool?*YesNoIf yes, for how long? what was the reason for absence?Has your child ever repeated a year?*YesNoIf yes, which year?Has your child been supported by a teacher's aide or specialist teacher?*YesNo(If yes, how many hours/week?)Which subjects/activities does your child find easy or enjoyable?*Which subjects/activities does your child dislike or find difficult?*Does your child have any difficulties with the following?* Behaviour Listening Sleeping Balance Making friends Learning new things Concentrating Co-ordination Expressing thoughts and feelings Dressing himself/herself Understanding what is said Sensitive to noise/touch or different textures Speaking clearly Speaking fluently OtherPlease give examples* Plese indicate if any concerns have been raised regarding the following areas of your child's learning Reading Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Spelling Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Maths Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Writing Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Attention/ConcentrationYear concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Memory Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Speech and language Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Reading Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Reading Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc)Emotions and behaviour Year concerns notedWho noted concerns?DetailsAction taken? (e.g. private tuition, etc) Strengths and Challenges What do you see as your child's strengths?*What do you see as your child's challenges?*What do you hope to gain by attending Kids First Children's Services?* Please provide any additional information that is relevant to your child's current needs and that may be helpful to the health professional/s assisting and/or assessing your child. (e.g. Other services involved in your child's support; your family's cultural, religious, language diversity; custody and/or care arrangements affecting your child; Medicare or FaHSCIA funded support plans) Comment*NameThis field is for validation purposes and should be left unchanged.