Sports & Spinal Paediatric Intake Form

We are dedicated to providing the best possible care for your child. In order to serve you better, please take the time to answer the following questions. We will discuss these in more detail when our clinician meets you. Your answers will be kept strictly confidential as part of your child’s clinic records. Thank you for your time!

Name(Required)

(Example: Delayed Gross Motor Skills, Lack of attention, Delay in speech Sensory Problem, etc.)
(Example: At birth, since first grade, noticed at age 8 months, etc.)

What level of difficulty (if any) is your child currently experiencing the following areas:

Gross motor skills (running, jumping, climbing)(Required)
Play
Fine motor skills (Drawing, craft, playing games)(Required)
Play

Educational

Reading(Required)
Spelling(Required)
Writing(Required)
Scissor Skills(Required)
Using their hands for learning and play activities(Required)

Self-Care

Dressing (including buttons and fasteners)(Required)
Using cutlery(Required)
Toileting(Required)
Grooming (brushing teeth and hair, bathing)(Required)

Speech and Language:

Understanding what is said(Required)
Expressing themselves using language(Required)

Behavioural:

Attention(Required)
Impulse control(Required)
Organising themselves(Required)
Managing emotions(Required)

Social Skills:

Playing with others(Required)
Making and keeping friends(Required)

(Example: CP, ASD Category 2, etc.)
(Example: OT, Speech, Vision Therapist, etc.)
Do you have funding through:(Required)
Does your child have any sensory problems, the clinician should be aware of? (Example: Hearing difficulties, visual difficulties, wearing glasses, does not like crowded areas, etc.)
In the first two years, did the child experience: (Check all that apply)

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