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PressTABandjumpfromonefieldtothenext基础信息GENERALINFOMATION重要提示:儿童姓名及家长姓名必须与证件所示一致IMPORTANT:FormalNameofChildandParentsMUSTMATCHPassportorNational填表日期(年/月/日)Today'sDate(YY/MM/DD)填表人/PersonCompletingForm:与儿童关系/RelationshiptoChild:儿童姓名/Child'sName:性别/Gender:女/Female男/Male儿童昵称/Namechildpreferstobecalled:民族/Race/Ethnicity出生年月(年/月/日)/Dateofbirth(YY/MM/DD)年纪/Age:出生地/PlaceofBirth:儿童国籍/Child'sNationality:儿童证件号/Child'sPassport/Identification#:现居住城市/CurrentCity:何时搬来此地(年/月/日)/DateMovedtoCurrentCity(YY/MM/DD)完整家庭地址/Fullhomeaddress:家庭电话/Homephonenumber:母亲姓名Mother'sName:父亲姓名Father'sName:母亲手机号Mother'smobilenumber:父亲手机号Father'smobilenumber:母亲邮件Mother'se-mailaddress:父亲邮件Father'semailaddress:母亲工作单位Mother'sEmployer:父亲工作单位Father'sEmployer:母亲职业Mother'sOccupation:父亲职业Father'sOccupation:主要联系人Primarycontactperson:母亲Mother父亲Father其他,若选择,请提供姓名,联系方式,与儿童的关系Other;IfChecked,pleaseprovidename,relationshiptochild,phonenumberandemail:兄弟姐妹的姓名及年龄Namesandagesofsiblings:就读学校NameofSchool:在家使用语言Language(s)spokenathome:年级,班级Grade/YearLevelandClass:儿童主导语言Child'sdominantlanguage:在校使用语言Language(s)spokenatschool:您对儿童的健康,发育及行为方面的担忧在于Whatareyourmainconcernsaboutyourchild'shealth,developmentand/orbehavior为什么你决定在此时联系我们WhydidyoudecidetoapproachLIHOlivia'sPlaceatthistime谁介绍儿童来此Whohasreferredthechild我们可否联系介绍人以获取额外信息/说明Maywecontactthereferrerforadditionalinformationorclarification是Yes否No(若是,请提供介绍人/机构名称及联系方式)(Ifyes,pleaseprovideaspecificname,organizationifappropriate,andcontactinformation)若儿童是被介绍来此的,您是否同意介绍人的观点Ifyourchildhasbeenreferred,doyouagreewiththereferral是Yes否No评论Comments:儿童强项是什么您欣赏儿童的哪些特质请提供详细描述Whatareyourchild'sstrengthsWhatqualitiesaboutyourchilddoyouparticularlyenjoyPleaseprovidedetails什么能激励儿童儿童的爱好/兴趣请提供详细描述WhatmotivatesyourchildWhatareyourchild'shobbies/interestsPleaseprovidedetails儿童的儿科医生/常用医院NameofYourChild'sLocalPediatrician/PrimaryMedicalCareProvider长和大蕴是否可以联系,以获取更多信息MayWeContactforMoreInformation是Yes否No长和大蕴是否可以直接将报告发至儿童的儿科医生Sendacopyofformalreportsdirectlytothechild'spediatrician:是Yes否No电话Phone:邮件Email:主要担忧BRIEFAREASOFCONCERN您对孩子的语言表达能力和发音是否担心Doyouhaveanyconcernsabouthowyourchildtalksandmakesspeechsounds不担心No担心Yes有一些Alittle评论Comments:您对孩子的理解能力是否担心Doyouhaveanyconcernsabouthowyourchildunderstandswhatyousay不担心No担心Yes有一些Alittle评论Comments:您对孩子灵活使用双手和手指的能力是否担心Doyouhaveanyconcernsabouthowyourchilduseshisorherhandsandfingerstodothings不担心No担心Yes有一些Alittle评论Comments:您对孩子灵活使用双臂和双腿的能力是否担心Doyouhaveanyconcernsabouthowyourchilduseshisorherarmsandlegs不担心No担心Yes有一些Alittle评论Comments:您对孩子的日常行为表现是否担心Doyouhaveanyconcernsabouthowyourchildbehaves不担心No担心Yes有一些Alittle评论Comments:您对孩子和其他人相处的能力是否担心Doyouhaveanyconcernsabouthowyourchildgetsalongwithothers不担心No担心Yes有一些Alittle评论Comments:您对孩子的自我学习能力和自理能力是否担心Doyouhaveanyconcernsabouthowyourchildislearningtodothingsforhim/herself不担心No担心Yes有一些Alittle评论Comments:您对孩子在接受学龄前或学校教育时的学习能力是否担心Doyouhaveanyconcernsabouthowyourchildislearningpreschoolorschoolskills评论Comments:其他Other:喂养/吞咽Feeding/Swallowing:矫形器Orthopedic:(例如,脚尖走路,斜颈)(e.
g.
,ToeWalking,Torticollis)感统处理SensoryProcessing:是Yes是Yes是Yes否No否No否No若有上述问题存在,请详细描述Ifyestoanyoftheabove,pleasegivedetails请提供其他方面的担忧(发育或其他)Pleaseindicateanyadditionalareasofconcern(developmentalorother)针对您的担忧,是否已有特定的诊断Doesyourchildhaveaspecificdiagnosisrelatedtoyourconcern是Yes否No若是,请详细描述Ifyespleasegivedetails健康史HEALTHHISTORY孕期及生产Pregnancy&Birth儿童出生情况Wasyourchildborn足月,周Full-term,bornatweeks早产,周Premature,bornatweeks生产Delivered:顺产Vaginal剖腹产CaesareanSection若剖腹产,原因IfCaesarean,Why怀孕,生产及下次生产时是否有什么问题/Werethereanyproblemsduringthepregnancy,delivery,orfollowingdelivery是Yes否No若是,请提供详请Ifyespleasegivedetails儿童出生后几月内的健康状况请提供详请Howwasyourchild'shealthduringhisorherearlymonthsoflifePleasegivedetails发育Development在什么年纪,儿童开始Atwhatagedidyourchild:独立坐sitalone独立走walkalone说话saywords上厕所训练toilettrain若您担心儿童的发育情况,是从儿童几岁开始的Ifyouareconcernedaboutyourchild'sdevelopment,atwhatagedidyoubegintoworry其他健康信息OtherHealthcareInformation最近一次听力测试Detailsoflatesthearingtest:日期Date:无None结果Result:正常Normal不正常Abnormal未知Unknown详请Details:最近一次视力测试Detailsoflatestvisiontest:日期Date:无None结果Result:正常Normal不正常Abnormal未知Unknown佩戴眼镜Wearsglasses:是Yes否No详请Details:药物史&过敏史Medications&Allergies请提供儿童正在服用的药物/维生素Pleasegivedetailsofanymedication/vitaminsyourchildistaking:无None儿童是否有过敏情况Doesyourchildhaveanyallergies是Yes否No若是,请提供详请Ifyespleasegivedetails药物过敏:Indicatespecificallergiestomedicine:药物和治疗史Medical&TherapyHistory描述主要健康问题/诊断及开始的日期,年龄Describeanymajormedicalproblems/diagnosesandtheirdatesoragetheybegan:住院,手术,头外伤,脑震荡,失去意识(注明日期)Hospitalizations/Surgeries/HeadInjuries/Concussions/Lossofconsciousness(withdates)儿童是否接受过言语治疗,精细动作治疗,大动作治疗的评估Hasyourchildhadanevaluationforspeech-languagetherapy,occupationaltherapy,orphysicaltherapy是Yes(言语ST精细动作OT大动作PT)无No儿童是否接受过言语,精细动作,大动作的治疗Hasyourchildeverattendedtreatmentwithspeech-languagetherapy,occupationaltherapy,orphysicaltherapy是Yes(言语ST精细动作OT大动作PT)无No儿童是否接受过发育,行为及学习能力的评估Hasyourchildeverbeenevaluatedfordevelopmental,behaviororlearningproblems是Yes否No若是,何时谁提供的评估何种评估您是否被告知评估结果请提供相关报告及详请IfYes,WhenWhoprovidedtheevaluationWhattypeofEvaluationWereyoutoldabouttheresultsPleaseattachanyrelevantreportsandprovidedetails儿童是否曾看过或接受过神经科医生的治疗Hasyourchildeverbeenseenortreatedbyaneurologist是Yes否No若是IfYes,何时When哪位医生Whowasthedoctor何种检查(脑电图,脑扫描等)TypesofTests(EEG's,brainscans,etc.
)若有,开了哪些药物Whatmedications,ifany,wereprescribed儿童是否接受过精神科或心理科的治疗Hasyourchildeverreceivedanypsychiatricorpsychologicaltreatment是Yes否No若是,何时何种治疗,持续多久谁提供的治疗IfYes,WhenWhattypeoftreatmentandhowlongdidthetreatmentlastWhoprovidedthetreatment儿童是否接受过行为,情绪控制方面的药物治疗Hasyourchildeverreceivedmedicationforbehaviororemotionalproblems是Yes否No若是,哪位医生,开了哪些药,服用剂量,服用周期IfYes,whowasthedoctor,whattypeofmedicationdidyourchildtake,atwhatdose,andforhowlong其他信息OtherInformation还有其他您希望我们了解的有关儿童的情况请提供详请或在需要的基础上,扩充以上的信息IsthereanythingelsethatyouwouldlikeustoknowaboutyourchildPleaseprovidemoreinformationorexpandoninformationaboveasneeded.
预约及交流偏好Scheduling&CommunicationPreferences您以及儿童希望由谁来做评估,治疗Doyouandyourchildpreferevaluationandtreatmentwith:男性治疗师MaleClinician女性治疗师FemaleClinician均可DoesnotMatter您是否需要以下所列服务(可多选)Areyouseekingaspecifictypeofservice(s)(checkallthatapply):儿科发育/行为Developmental/BehavioralPediatrician言语治疗Speech-LanguageTherapy喂养/吞咽Feeding/Swallowing行为服务BehavioralServices精细动作治疗OccupationalTherapy大动作治疗PhysicalTherapy心理服务PsychologyServices学习支持/特殊教育LearningSupport/SpecialEducation我不清楚,我需要更多的信息做决定I'mnotsure.
Ineedmoreinformation.
您是否需要预约某位特定的医师或专家Areyouseekingevaluation/treatmentwithaspecificclinicianorspecialist是Yes否No若是,请提供详请Ifyespleasegivedetails儿童偏向在周几,何时间段来本院,可多选Whattimeofdayandwhatdaysoftheweekworkbestforyourchild'sschedulePleasecheckallthatapply:周一Monday上午Morning(9:00am-12:00pm)下午Earlyafternoon(12:00-3:00pm)晚上Lateafternoon(3:00-6:00pm)周二Tuesday上午Morning(9:00am-12:00pm)下午Earlyafternoon(12:00-3:00pm)晚上Lateafternoon(3:00-6:00pm)周三Wednesday上午Morning(9:00am-12:00pm)下午Earlyafternoon(12:00-3:00pm)晚上Lateafternoon(3:00-6:00pm)周四Thursday上午Morning(9:00am-12:00pm)下午Earlyafternoon(12:00-3:00pm)晚上Lateafternoon(3:00-6:00pm)周五Friday上午Morning(9:00am-12:00pm)下午Earlyafternoon(12:00-3:00pm)晚上Lateafternoon(3:00-6:00pm)周六Saturday上午Morning(9:00am-12:00pm)下午Earlyafternoon(12:00-3:00pm)晚上Lateafternoon(3:00-6:00pm)邮件许可E-MailConsent是Yes否No我授权长和大蕴通过邮件方式和我交流病患情况,我的邮箱地址为IauthorizeLIHOlivia'sPlacetocommunicatemedicalinformationviaelectronicmailtomye-mailaddress:短信许可及预约提醒SMSconsentforinformationandappointmentreminders是Yes否No注明手机号码Indicatemobilenumber:您如何得知长和大蕴HowdidyouhearaboutLIHOlivia'sPlace你是否愿意收到我们的定期邮件Wouldyouliketobeaddedtoourmailinglist是Yes否No若是,请提供邮箱地址Ifyes,whichemailaddress我声明上述提供信息真实,正确ICERTIFYTHATTHEINFORMATIONGIVENABOVEISTRUEANDCORRECT患者/家长或授权代表Patient/ParentorAuthorizedRepresentative签名Signature:日期Date:YYYY_____MM_____DD姓名Name:感谢您完成此份表格;我们会尽快联系您.
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