- 10 -
/ Building # 9" Road 278,New Maadi,
Cairo11434,
Tel: 516 3965 – 516 3967
Fax: 5203110Application For Assessment
Ages: 11+ years old
· Child’s Name:______
(First) (Middle) (Family Name)
Age: _____Male/Female:______Nationality: ______Date of Birth:______(d/m/yr)
Place of Birth: ______
· Home Address: (please indicate district, i.e. Maadi, Zamalek, Giza, Sidi Bishr, …etc)
______
· Father’s Name: ______
Tel Hm #: ______Wk #______Mob #______
Email: ______
Address (if different than child’s) ______
· Mother’s Name: ______
Tel Hm #: ______Wk #______Mob #______
Email: ______
Address (if different than child’s) ______
· Primary language of family: ______Language preference for intake: ______
· If non Egyptian, how long do you expect to be a resident in Egypt? ______
· Please list specific problems your child is experiencing and / or your concerns: ______Please list what you would like us to provide: ______
Office use only: Date received: Paid: (yes/no) Date Entered:· How did you learn about the center? ______
Educational History
Schools attended
(List all schools attended, starting with current school.)
1) Current School’s Name______
Address______
Grades attended______
Language of Instruction______
Teacher’s Name ______Current Class______
Phone Number______
School will only be contacted with your permission.
2) School’s Name______
Address______
Grades attended______
Language of Instruction______
3) School’s Name______
Address______
Grades attended______
Language of Instruction______
4) School’s Name______
Address______
Grades attended______
Language of Instruction______
Please attach samples of current work and or progress reports if available.
Use back of paper if need more space for additional schools.
Has your child had previous evaluations? If so, when, where, type of assessment and outcome.
It would be helpful if you could attach copies of reports (including medical).
______
Has your child received any special treatments (e.g. diets, medications, speech therapy, physiotherapy)? If so please describe below, including approximate dates.
______
*Please complete the attached parent questionnaire as accurately, and in as much detail as you can. Some sections and/or questions may not apply to your child as the questionnaire covers a broad age range. Either cross through or write N/A (not applicable) in these sections.
Thank you in advance for your consideration and time.
______
Summary of results and action taken______
______
The following checklists help us to decide whether there are any early medical factors might be important. The checklist entitled “Possible Pregnancy Problems” concerns the pregnancy with this student, except for items 1.12 and 1.13 which refer to previous pregnancies. The “Newborn Infant Problems” checklist is about the baby’s first month of life. Please read each list, and then put an X in the appropriate column following each item.
1.1 / Had bleeding during first three months
1.2 / Had bleeding during second three months
1.3 / Had bleeding during last three months
1.4 / Gained 30 or more pounds (14 kgs.) (specify ______)
1.5 / Had toxemia
1.6 / Had to take medications*
1.7 / Vomited often
1.8 / Got hurt or injured
1.9 / Gained less than 15 pounds (7 kgs.) (specify ______)
1.10 / Took narcotic drugs
1.11 / Drank much alcohol
1.12 / Had previous miscarriages
1.13 / Had previous premature baby(ies)
1.14 / Had an infection
1.15 / Smoked one pack (or more) of cigarettes a day
1.16 / Labor lasted longer than 12 hours
1.17 / Had a cesarean section
1.18 / Had a difficult delivery
1.19 / Was put to sleep for delivery
1.20 / Labor lasted less than two hours
1.21 / Length of pregnancy______months
*Specify any medications: Other pregnancy problems/illnesses:
1. ______1. ______
2. ______2. ______
3. ______3. ______
2.0 / NEWBORN INFANT PROBLEMS / True / Not True / Cannot Say2.1 / Born with cord around neck
2.2 / Injured during birth
2.3 / Had trouble breathing
2.4 / Got yellow (jaundice)
2.5 / Turned blue (cyanosis)
2.6 / Was a twin or triplet
2.7 / Had an infection
2.8 / Was given medications
2.9 / Had seizures (fits, convulsions)
2.10 / Had diarrhea
2.11 / Needed oxygen
2.12 / Was in hospital more than seven days
2.13 / Gagged often
2.14 / Vomited often
2.15 / Born with heart defect
2.16 / Born with other defect(s)
2.17 / Had trouble sucking
2.18 / Had skin problems
2.19 / Was very jittery
2.20 / Baby’s birth weight ______¨ Ibs. ¨ kgs.
Please list any other problems.
1. ______
2. ______
3. ______
4. ______
Following are two checklists of conditions children sometimes have. The checklist entitled “Health Conditions” is about any medical conditions this student may have had. The “Functional Conditions in Early Life” checklist includes some personality or behavior problems he or she may have had. In both lists, if the student has ever had any of these conditions, please put an X in the column under the age at which the condition(s) occurred. If a condition occurred over a long period, or over and over again, please check the columns for each age during which the condition existed. If the student has never had the condition, put an X in the “Never” column.
years / 1-5 years / 5-10 years / 10-15 years / Over
15 years
3.1 / Ear infection(s)
3.2 / Rashes or skin problems
3.3 / Meningitis
3.4 / Seizures (convulsions) or spells
3.5 / High fevers (over 103°F or 39°C)
3.6 / Pneumonia
3.7 / Asthma
3.8 / Slow weight gain
3.9 / Trouble with ears or hearing
3.10 / Trouble with eyes or vision
3.11 / Bowel problems
3.12 / Hospitalization(s)*
3.13 / Surgery (operations)*
3.14 / Serious injury(ies)
3.15 / Food allergies
3.16 / Other allergies
3.17 / Anemia (low blood count)
3.18 / Lead poisoning
3.19 / Other poisoning or overdose
3.20 / Heart problems
*Please give reasons for hospitalizations or surgery.
______
years / 1-5 years / 5-10 years / 10-15 years / Over
15 years
3.21 / Kidney or urinary problems
3.22 / Got sick after a shot (immunization)
3.23 / Other important illnesses (specify):
a.
b.
3.24 / Medications used over a long period (specify):
a.
b.
c.
4.0 / FUNCTIONAL CONDITIONS IN EARLY LIFE / Never / 0-1 years / 1-5 years / 5-10 years
4.1 / Feeding difficulty or eating problem
4.2 / Poor appetite
4.3 / Unwillingness to try new foods
4.4 / Very unpredictable appetite
4.5 / Overeating
4.6 / Colic
4.7 / Constipation
4.8 / Abdominal pains
4.0 / FUNCTIONAL CONDITIONS IN EARLY LIFE (continued) / Never / 0-1 years / 1-5 years / 5-10 years
4.9 / Trouble falling asleep
4.10 / Trouble staying asleep
4.11 / Very unpredictable length of sleep
4.12 / Very heavy sleeping
4.13 / Overactivity
4.14 / Head banging
4.15 / Rocking in bed
4.16 / Temper tantrums
4.17 / Self- destructive behavior
4.18 / Difficulty in being comforted or consoled
4.19 / Stiffness or rigidity
4.20 / Looseness or floppiness
4.21 / Crying often and easily
4.22 / Shyness with strangers
4.23 / Bashfulness with new acquaintances
4.24 / Irritability
4.25 / Extreme reaction to noise or sudden movement
4.26 / Difficulty in keeping to a schedule
4.27 / Trouble getting satisfied
4.28 / Desire to be help too often
4.29 / Failure to be affectionate toward parents
4.30 / Unwillingness to go along with change in daily routine
4.31 / Tendency to make odd sounds, grunts, or snorts
4.32 / Tendency to twitch or jerk arm(s) or head often
4.33 Was child breast-fed? ¨ Yes (until age _____ months) ¨ No
Following is a checklist of early accomplishments of children. Please put an X next to each item under the column giving the age at which this “milestone” first occurred.
5.1 / Sat up without help
5.2 / Crawled
5.3 / Walked alone (10-15 steps)
5.4 / Walked up stairs
5.5 / Rode a tricycle
5.6 / Caught a big ball
5.7 / Spoke first words (Mama, Dada, etc.)
5.8 / Put words together (Daddy bye-bye, Mama home, etc.)
5.9 / Spoke 2-3 word sentences
5.10 / Spoke clearly so strangers understood
5.11 / Used fingers to feed self
5.12 / Used a spoon
5.13 / Fully bowel trained
5.14 / Fully bladder trained
5.15 / Able to dress self
5.16 / Able to tie shoelaces
5.17 / Able to separate easily from mother (for school, play, etc.)
5.18 Did this student attend a preschool/nursery school? ¨ Yes ¨ No
If so, were any problems with behavior noted? ¨ Yes ¨ No
Were any problems with learning noted? ¨ Yes ¨ No
5.19 Was this student retained in a grade? ¨ Yes ¨ No
If so, when?______
Following is a checklist of twelve characteristics or conditions that may run in families. We are interested in whether anyone in the family other than this student has had any of these. Please put an X in the column of the family member(s) who have or have had each characteristic or condition. If more than one brother or sister has or has had one of these characteristics or conditions, put an X for each one in the appropriate column (for example, if there were two brothers who had trouble learning how to read, you would put two Xs next to item 6.2 under the column “Child’s Brother(s)”. The “Others” column (for family members such as cousins, aunts, uncles, grandparents) should be used in the same way.
6.0 / FAMILY HISTORY / Child’s Mother / Child’s Father / Child’s Brother(s) / Child’s Sister(s) / Others(Specify)
6.1 / Hyperactive as a child
6.2 / Trouble learning to read
6.3 / Trouble with arithmetic
6.4 / Trouble with writing
6.5 / Speech problems
6.6 / Behavior problems in childhood
6.7 / In trouble as a teenager
6.8 / Kept back in school
6.9 / An honor student
6.10 / Mental retardation
6.11 / Depression or manic depression
6.12 / Drug or alcohol problems
6.13 Father’s present age______School level completed______
Present occupation ______
General Health ______
6.14 Mother’s present age:______School level completed______
Present occupation ______
General Health ______
6.15 Brother(s): Age(s) ______
6.16 Sister(s): Age(s) ______
______
6.0 / FAMILY HISTORY (continued)6.17 What is the principle language spoken at home? ______
Indicate others that are sometimes used. ______
Please check any of the following that are true of this student:
6.18 ¨ Was adopted ¨ Is a foster child
6.19 Parents are ¨ separated or ¨ divorced. ¨ One or ¨ both parent(s) are deceased.
If so, student lives mainly with (check one or more):
¨ Mother ¨ Stepmother ¨ Grandparent(s)
¨ Father ¨ Stepfather ¨ Other______
The following is a checklist of early educational experiences. Please put an X next to each item in the column that best describes this student during elementary school. The first item pertains to nursery school; the others pertain to grades one through six.
7.0 / EARLY EDUCATIONAL EXPERIENCE / Didwell / Had some
problems / Had serious
problems / Cannot
say
7.1 / Behavior in nursery school or preschool
7.2 / Learning to read in 1st and 2nd grade
7.3 / Reading level in 3rd to 6th grade
7.4 / Learning to write the alphabet
7.5 / Behavior in 1st and 2nd grade
7.6 / Behavior in 3rd and 4th grade
7.7 / Behavior in 5th and 6th grade
7.0 / EARLY EDUCATIONAL EXPERIENCE (continued) / Did
well / Had some
problems / Had serious
problems / Cannot
say
7.8 / Learning arithmetic in 1st, 2nd, and 3rd grade
7.9 / Learning arithmetic in 4th, 5th, and 6th grade
7.10 / Learning to spell in 1st, 2nd, and 3rd grade
7.11 / Learning to spell in 4th, 5th, and 6th grade
7.12 / Learning to tell time
7.13 / Learning days of week, months of year
7.14 / Learning to swim
7.15 / Learning to ride a bicycle
7.16 / Learning to catch and throw a ball
7.17 / Learning to follow rules
7.18 / Learning to obey adults
7.19 / Learning to get along with other children
7.20 / Staying out of trouble
7.21 / Learning to write words/sentences
7.22 / Learning to hold a pencil properly
7.23 / Learning to trace and draw
7.24 / Learning cursive writing
7.25 / Getting homework done in 4th, 5th, and 6th grade
7.26 / Acquiring good study habits
7.27 / Learning to pay attention in school
Following is a checklist of skills and abilities (page 13) and a list of interests (page 14). Please put and X to each item in the column that best describes this student’s current ability or interest. If she or he has had no experience with a particular item, leave it blank.
8.1 / Catching and throwing a ball
8.2 / Running fast
8.3 / Playing most sports
8.4 / Dancing
8.5 / Drawing/art work
8.6 / Building/fixing things
8.7 / Understanding spoken directions
8.8 / Understanding jokes and stories
8.9 / Speaking clearly
8.10 / Telling stories/describing things that have happened
8.11 / Remembering where to find things
8.12 / Remembering appointments
8.13 / Making friends
8.14 / Understanding other people’s problems
8.15 / Using his/her imagination
8.16 / Understanding what he/she reads
8.17 / Reading fast enough
8.18 / Figuring out unfamiliar words while reading
8.19 / Handwriting (legibility)
8.20 / Writing reports
8.21 / Writing fast enough
8.22 / Spelling accurately
8.23 / Learning new math skills
8.24 / Doing well on math tests
8.25 / Using a computer in school
8.26 / Completing homework
8.27 / Remembering instructions for assignments
8.28 / Knowing what and how to study for a test
8.29 / Learning new words (vocabulary)
8.30 / Organizing study time
8.31 / Please list any other strong or poor skills:
8.32 On average, how many hours per week does this student watch television? ______hours