341 Mona Vale Rd, St. Ives NSW 2075 Australia, 02 9440 0543

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Cellfield Intake Questionaire

The clinic is located at 341 Mona Vale Rd., St Ives. You can drive in and park behind the clinic.

Please complete following questionaire. CONTACT DETAILS Parent or Guardian name: Child name: Age: Address: City/Suburb:    Phone number (H):       (W):      (M):   Preschool    Kindergarden    Primary    High School    Adult    School year 1 2 3 4 5 6 7 8 9 10 11 12 MEDICAL HISTORY Has your child had any of the following? Middle ear infections ('glue ear') Insertion of 'grommets' Tonsillitis or frequent sore throats Hearing problems Problems with vision (e.g. blurred vision, watery eyes, bothered by glare) Headaches Convulsions Serious Injuries: Other medical conditions or complaints: Does your child take medication? Yes   No Names of medications: Has your child had their hearing tested? Yes   No Has your child had their eye sight tested? Yes   No FAMILY HISTORY Has anyone in your child's immediate or extended family had difficulties with: Articulation Language skills Stuttering Dyslexia Reading or learning Has your child ever received special education help? (e.g. special reading group, language support class)? Yes   No In your opinion, what is your child's current achievement at school in the following areas?   Please tick boxes Above Average Average Below Average   Reading accuracy   Reading comprehension   Spelling   Written expression   Oral (verbal) expression   Handwriting   Mathematics Do any of the following apply to your child? Dislikes school Blames teacher for difficulties Complains school is boring Refuses to cooperate with teachers Teachers report 'discipline' problems Is not motivated to complete class or homework activities Frequently hands in 'sloppy' work or neglects to hand in assignments Comprehension Does your child have difficulties: Understanding questions Following instructions correctly Understanding indirect requests and sarcastic comments Following stories as a whole, drawing conclusions, making predictions Understanding that the meaning of a word can change depending on the context Auditory Processing Does your child have difficulties: Have difficulties saying speech sounds (e.g. 'lellow' fpr 'yellow', 'fum' for 'thumb') Have difficulties saying words of several syllables (e.g. 'hostipal' for 'hospital', 'puter' for 'computer') Fail to understand rhymes Confuse similar-sounding words (e.g. 'cone' for 'comb') Have difficulties identifying the number of syllables or sounds in words BEHAVIOUR (Please tick as appropriate) Activity Level Cannot keep still or stay quiet; 'hyperactive', restless Lethargic, often tired, fatigues quickly Attention Cannot concentrate on a task for long Needs to be called back to task continually Cannot ignore 'distractions'; overly aware of nearby sounds, sights and smells Movement and Balance Poor balance on play equipment Difficulties climbing or descending stairs Seems overly sensitive to movement; becomes carsick regularly Constantly moving; often swinging, twirling, bouncing and rocking Visual Perception Difficulties matching colours, shapes and sizes Difficulties completing puzzles, uses 'trial and error' to place pieces Reverses words, letters or number after Year One Skips words, phrases or lines when reading Loses place when reading or copying; needs finger or marker to keep place Difficulties with smooth eye-tracking (following objects with eyes) Is there any other information relevant to your child's difficulties that you would like to tell us about? PRINT FORM (for your own records) ... SUBMIT FORM (to Speech Language Learning) ...