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 Mobile Phone*Home PhoneEmail* How did you find out about Kids First?*How can we help you?*What are your major concerns for your child? What advice or help are you looking for?What impacts are your child's difficulties having on your child and your family?*How are these challenges affecting your child's learning, participation, friendships, self-esteem, family relationships, behaviour etc 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 2Who lives with your child? (Tick all that is relevant) Parent 1 Parent 2 Siblings Grandparents Other Preschool Nameor School NameDays attending Monday Tuesday Wednesday Thursday Friday ClassTeacher's NameWhat difficulties is your child experiencing at preschool or school? (Please be as specific as possible. What happens? Where? How Often?)*Please describe any concerns that have been 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', please 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 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 Occupational Therapist Psychologist Upload 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 ...... ? When did your child start to use pencils/crayons?At what age did your child start to babble?At what age did your child start to say single words?At what age did your child start to tolerate solids for the first time?At what age did your child start to show interest in toysWhen did your child start to drink well from a cupAt what age was your child able to join 2 - 3 wordsAt what age did your child start to sit alone without supportAt what age did your child start to feed him/herself?At what age did your child start to crawl?At what age did your child start to dress him/herself?At what age was your child able to walk by him/herself?At what age was your child toilet trained (by day)?Is your child toilet trained by night? If so, at what age was this achieved? Has your child suffered from any of the following illnesses and conditions? Please provide details of frequency and when this last occurred. Does your child suffer from any allergies?Does your child suffer from asthma?Has your child had any heavy colds or flu in the last 12 months? If so, how many and for how long were they affected?Does your child suffer from croup?Has your child suffered from ear Infections in the last 2 years? If so, on how many occasions were they affected?Has your child had tonsilitis in the last 12 months?Does your child suffer from frequent headaches?Does your child suffer from anxiety?OtherHas 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 your eats, consistency of food, when your child eats, how much your child eats, how your child eats, who feeds your child, where your 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 When were concerns about your child raised?Who by?Details (Please provide as much detail as you feel is relevant)Action taken? (e.g. therapy, counselling, further investiagtion wth medical professionals, learning support at school, private tuition, etc)Spelling Maths Writing Attention/ConcentrationMemory Speech and language Reading Reading Emotions and behaviour 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*EmailThis field is for validation purposes and should be left unchanged.