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General Screening Form
Please take a moment to answer the questions below regarding your child. Your responses will help us better understand your child’s needs and determine the most appropriate course of action. Once we receive your answers, a member of our office will contact you to discuss your concerns in more detail and provide guidance on the next steps. Thank you for trusting us with your child’s care!
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Caregiver Name (First, Last) *
Email address *
Phone number *
Child's Age *
Does your child have difficulty running, jumping, climbing stairs, or playing on playground equipment compared to peers?
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Does your child frequently trip, fall, or have trouble maintaining balance during activities?
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Does your child get tired easily during physical activities or struggle to lift or carry age-appropriate objects?
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Do you notice poor posture or unusual walking patterns, such as limping, toe-walking, or uneven shoulders?
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Does your child complain of pain or discomfort in their muscles or joints during or after physical activities?
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Does your child avoid certain foods due to their texture, taste, or smell, or show distress during mealtimes?
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Does your child struggle with tasks like holding a pencil, using scissors, buttoning clothes, or tying shoes?
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Does your child seem overly sensitive or underreactive to sounds, textures, lights, or other sensory inputs?
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Does your child have difficulty with age-appropriate tasks such as feeding themselves, dressing, or brushing their teeth?
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Does your child have trouble staying focused on tasks or seem easily distracted during play or schoolwork?
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Does your child avoid certain play activities or have difficulty playing cooperatively with other children?
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Does your child have frequent emotional outbursts, difficulty calming down, or extreme reactions to minor situations?
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Does your child often seem nervous, worried, or overly fearful of situations or objects?
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Does your child avoid interacting with peers or have trouble making or keeping friends?
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Have you noticed changes in your child’s sleep patterns, such as difficulty falling or staying asleep, or unusual changes in eating habits?
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Has your child exhibited behaviors such as withdrawal, aggression, or repetitive actions that concern you?
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Does your child have difficulty being understood by family members or unfamiliar listeners? 
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Does your child struggle to form sentences, express ideas, or use age-appropriate vocabulary?
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Does your child seem to have difficulty understanding or following simple verbal directions?
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 Is your child able to follow routine directives with gesture cues (I.e. pointing)? 
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Does your child have a hoarse voice, unusual pitch, or frequent stuttering when speaking?
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