V ISUAL SENSATION: Does your child:

  • Have difficulty maintaining eye contact?
  • Have a diagnosed visual effect?
  • Make reversals when copying?
  • Have difficulty discriminating colors, shapes?
  • Like or dislike puzzles?
  • Appear sensitive to light?
  • Resist having vision occluded?
  • Become over excited when confronted with variety of stimuli?
  • Have an attraction to spinning objects or vertical or horizontal lines?
  • Have an attraction to letters and numbers?
  • Likes to line up objects?
  • Likes to throw toy up in the air and watch them fall?
  • Explore objects using peripheral vision?
  • Squint or close one eye when looking at things?
  • Appear not to notice things in their environment or focus on minute detail?
  • Have a more than ordinary fascination with videos or computer

    When was the last time his/her eyesight was tested?

    • A UDITORY DEVELOPMENT

    Has your child experienced any problems with his/her hearing? (operations, infections, tubes)

    Ear infections? seldom ___ sometimes ____ often ______

    mild _____ moderate ______ severe ___

    Has your child had his/her hearing tested? If yes, what were the results?

    Are there any current/past hearing problems of which you are aware?

    AUDITORY SENSATION: Does your child:

  • Seem overly sensitive to sound?
  • Notices sounds in environment before others?
  • Doesn't notice sounds such airplane over hear
  • Miss some sounds or poorly discriminate sounds?
  • Seem confused about the direction of sounds?
  • Like to make loud or high pitched noises?
  • Have a diagnosed hearing loss?
  • Hear things before you hear them?
  • Easily distract by noise?
  • Frighten by the sound of certain machinery or toys?
  • Have you or others ever thought your child was deaf?

    • S PEECH AND LANGUAGE DEVELOPMENT

    How would describe your child's speech and language?

    Non- verbal _________

    Has a few words but doesn't use then appropriately ___

    Appropriate but below age level: ________

    Normal: __________

    If there has been speech and language testing, please give us the age level:

    Receptive language __________

    Expressive language _________

    Articulation:

    Speech unintelligible ______________

    Severe Problem _____________

    Serious but some intelligible speech _________

    Poor articulation but speech intelligible ____________

    Within normal limits ______________

    If your child is signing:

    1 or 2 approximations _____________

    Limited but appropriate ______________

    Signs fluently to make needs understood ____________