Down Syndrome Specialty Clinic: Intake Questionnaire

Center on Human Development and Disability

University of Washington

GENERAL INFORMATION:

Today’s Date:______________________________ Birth Date:________________________________

Child’s Name: _________________________________________________________________________

If in foster care, please provide DSHS/DCFS case worker’s name: ________________________________

Person completing form: ______________________ Relationship to child: ________________________

Legal Guardian YES / NO

Parent(s) Name: _____________________________ E-mail address: _____________________________

Preferred contact phone: ______________________
Address: _____________________________________________________________________________
City: ____________________________ State: _____________ Zip code: __________________________

Child’s Primary Care Physician: _________________________ Phone: ____________________________

Address: _____________________________________________________________________________
City: ____________________________ State: _____________ Zip code: __________________________
Phone number: __________________________ Fax Number: __________________________________

Insurance Carrier: ______________________________ Subscriber ID#: ________________________

Subscriber name: ______________________________ Subscriber Date of Birth: ________________

Please tell us who lives in your home:

Name Relationship to patient Age Special medical/behavioral needs?

List any medical providers who provide care for your child (for example cardiologist, neurologist,
gastroenterologist):
Doctors Name Specialty Area
Who referred you to our clinic? ___________________________________________________________

Was there a specific event that led to a referral to this clinic? YES / NO
If YES, what?
_____________________________________________________________________________________
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List any current diagnoses, other than Down syndrome, your child has (for example autism,
hearing/vision problem, heart condition, ADHD, other):
_____________________________________________________________________________________
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What are your primary concerns?

_____________________________________________________________________________________
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What do you hope to get from an evaluation at the Down Syndrome Specialty Clinic?
_____________________________________________________________________________________
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SPEECH PATHOLOGY:

What language(s) are spoken at home? _____________________________________________________

What percent/how much does your child HEAR of each language? ________________________
What percent/how much does your child SPEAK of each language? ________________________

How many words does your child have?

€ None
€ 1-5
€ 5-20
€ 20-50
€ 50-100
€ 100-200
€ 200 +

Does your child speak in sentences? YES / NO

How many gestures does your child have (high five, clap, wave, thumbs up etc.)?
€ None
€ 1-5
€ 5-20
€ 20 +
Does your child:
• Play pretend or make-believe (FOR EXAMPLE, pretend to from an empty cup, pretend to talk on a
phone, or pretend to feed a doll or stuffed animal)? YES / NO / SOMETIMES

• Make unusual finger movements near his or her eyes (FOR EXAMPLE, does your child wiggle his or
her fingers close to his or her eyes)? YES / NO / SOMETIMES

• Point with one finger to ask for something or to get help (FOR EXAMPLE, pointing to a snack or toy
that is out of reach)? YES / NO / SOMETIMES

• Show you things and share their interests with you (FOR EXAMPLE, showing you a flower, a
stuffed animal, or a toy truck)? YES / NO / SOMETIMES

• Respond to their name (FOR EXAMPLE, does he/ she look up, talk or babble, or stop what he/ she
is doing when you call his/her name)? YES / NO / SOMETIMES
• If something new happens, does your child look at your face to see how you feel about it (FOR
EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at
your face)? YES / NO / SOMETIMES

• Does your child look you in the eye when you are talking to him or her, playing with him or her,
or dressing him or her? YES / NO / SOMETIMES

• Does your child try to copy what you do (FOR EXAMPLE, wave bye-bye, clap, or make a funny
noise when you do)? YES / NO / SOMETIMES

GENETICS:

How was your child diagnosed?

€ Prenatal (before birth)
€ Postnatal (after birth)

Where was your child diagnosed?

• Name of Hospital / Clinic: _________________________________________________
• Name of physician / genetic counselor: ______________________________________

Have you met with a genetic counselor? YES / NO

If yes, list the name of the facility and genetic counselor:________________________________

Are you interested in discussing any of the following topics? Check all that apply.
€ Genetic causes of Down syndrome
€ Recurrence risks (What are the chances to have another child affected with Down syndrome?)
€ Health concerns and features of Down syndrome
€ Other_______________________________________________________________________
NUTRITION:

Do you have any concerns about your child’s growth, eating habits, food intake or meal time behavior?
(Please check below)
€ Overweight
€ Underweight
€ Constipation
€ Diarrhea
€ Vomiting
€ Chewing food
€ Swallowing food
€ Gagging/choking
€ Refusal to eat
€ Getting upset at meals
€ Comments: _____________________________________________________________________

Does your child have a feeding tube? YES / NO

COMMUNITY RESOURCES:

Does your child receive any of the following therapies outside of school or early intervention?
Therapy type Where? How often?
Speech
Feeding
Physical
Occupational
List other:

Are you interested in more information about:

€ Parent / sibling support groups
€ Developmental Disabilities Administration (DDA)
€ Supplemental Security Income (SSI)
€ Housing
€ Financial support
€ Respite Care
EDUCATION:

Current school & district (age 3 and up) OR early intervention (birth to age three) program name:
_____________________________________________________________________________________
Address: _____________________________________________________________________________
City: ____________________________ State: _____________ Zip code: __________________________
Phone number: __________________________ Fax Number: __________________________________

What therapies does your child get from their school or early intervention program?
Therapy type How often?
Speech
Feeding
Occupational
Physical
List other:

Does your child have an Individualized Education Plan (IEP) at his/her current school program? YES /
NO

Do you have concerns about your child’s IEP? YES / NO

If YES, what are they?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

AUDIOLOGY:

When did your child last have their hearing checked by an audiologist? _______________ (Month/Year)

Was the last hearing test normal? YES / NO

If NO, what were the results (mild, moderate, or severe hearing loss AND type of hearing loss:
conductive or sensorineural)? ____________________________________________________________

PSYCHOLOGY:

Do you have concerns about your child’s behavior? YES / NO

If yes, please let us know what your concerns are:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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PHYSICAL/OCCUPATIONAL THERAPY:

Please check any areas of concern regarding your child’s development.

FINE MOTOR: BEHAVIOR:

_____ Holds pencil or crayon awkwardly _____ Short attention span

_____ Has difficulty with writing _____ Tantrums frequently

_____ Awkward with manipulatives _____ Difficulty w/change in routine

(legos, game pieces, stringing small beads)
_____ Has unusual repetitive behaviors
_____ Has difficulty using scissors (e.g. flaps hands, toe-walks, makes noises, etc.)

_____ Difficulty handling spoon or fork _____ Poor eye contact

GROSS MOTOR: SELF-CARE:

_____ Clumsiness in walking or running _____ Dislikes some textures of clothes

_____ Seems weak; fatigues easily _____ Needs extra help w/dressing for age

_____ Avoidance or difficulty using _____ Overly sensitive to brushing teeth,

playground equipment shampoos, haircuts

_____ Fearful of heights, climbing _____ Toileting issues

_____ Picky eater

SENSORY PROCESSING:
_____ Chewing/swallowing problems
_____Overreacts to touch/ physical contact
_____ Awkward feeding self
_____ Frequent need for something in mouth

_____ Refuses certain food textures PLAY:

_____ Upset by loud noises _____ Has difficulty playing with others

_____ Seeks out movement excessively _____ Prefers to play alone

_____ Gets overwhelmed easily _____ Plays w/same toys over and over

_____ Doesn’t like hands messy _____ Hard time imitating others in play
OTHER COMMENTS:
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