Online Forms

Child Patient History

Patient First & Last Name

Date of Birth

Sask Health Card #

Parent/Guardian Name(s):

Parent Email Address

Parent Phone Number

Name of School

Grade

Do you have any concerns with their vision or motor skills? If so, please describe:

Other Conditions:

Please list any current medications:

Were they born?	Prematurely	Full-term	Unknown
How were they delivered?	Vaginally	C-section	Unknown
Were forceps used during delivery?	Yes	No	Unknown
Any complications during pregnancy?	Yes	No	Unknown
Any complications during birth?	Yes	No	Unknown
Was an incubator or oxygen used?	Yes	No	Unknown

When were the following milestones met:

Can they do the following:

Stand/Hop on one foot	Yes	No
Catch a ball	Yes	No
Ride a bike	Yes	No
Have difficulty with balance	Yes	No
Struggle with hand-eye co-ordination	Yes	No
Right or left handed	Right	Left

Do they:

Enjoy School	Yes	No	Sometimes
Enjoy reading	Yes	No	Sometimes
Enjoy being read to	Yes	No	Sometimes
Read at or above grade level	Yes	No	Sometimes
Comprehend what they read	Yes	No	Sometimes
Reach their potential in school	Yes	No	Sometimes
Print neatly	Yes	No	Sometimes
Reverse letters	Yes	No	Sometimes
Come home from school exhausted	Yes	No	Sometimes
Come home from school with headaches	Yes	No	Sometimes
Have any classroom adaptations	Yes	No	Sometimes

Do you and/or their teacher have any concerns with their school performance and/or behaviour?
If so, please describe:

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