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背景信息表

> 首页 » 关于我们 » 表格 » 背景信息表

步骤 1 字，最多 11

9%

Comments
这个字段是用于验证目的，应该保持不变。
请仔细阅读。
Child Details
Date*
YYYY dash MM dash DD
儿童全名*
第一页居中后一页
出生日期*
YYYY dash MM dash DD
性別*
- 男
- 女
年龄*
所需服务：*
- 心理咨询/心理学
- 教育支持
- 职业治疗
- 物理治疗
- 言语/语言治疗
- 其他
Other requested service*

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Guardian 1 Details
Guardian 1 Name*
前缀第一页后一页
Home Address*
街道地址地址2 (街道) 市邮编/邮政编码国家
Home Telephone*
Work Telephone*
Mobile Telephone*
电子邮箱*
Occupation*

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Guardian 2 Details
Guardian 2 Name*
前缀第一页后一页
Home Address*
街道地址地址2 (街道) 市邮编/邮政编码国家
Home Telephone*
Work Telephone*
Mobile Telephone*
电子邮箱*
Occupation*

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Referral Information
Who referred you to SPOT?
Please describe your child’s issues. Please include any information you feel is relevant:*
Has your child been evaluated for any of the issues listed above? If so, by whom and when? What were the findings?*

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Birth and Infancy Details
Difficulties Following Birth:
- Needed Oxygen
- Needed Incubation
- Had Trouble Sucking
- Intubation
- 其他
Other difficulties following birth:*
Difficulties During Infancy:
- Sleeping
- Irritable
- Limp
- Jittery
- Rigid
- Overactive
- Colic
- Under active
- 其他
Other difficulties during infancy:*
Weeks Gestation
Weight
APGAR Score
Length of hospital stay

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Child's Medical History
Ear Infections
- 是
年龄*
Frequency*
Tonsillitis
- 是
年龄*
Frequency*
Frequent Colds
- 是
年龄*
Frequency*
Tubes in Ears
- 是
年龄*
Frequency*
High Fever
- 是
年龄*
Frequency*
Respiratory Infections
- 是
年龄*
Frequency*
Allergies (please list all):
Seizures: (Frequency and when was most recent one?)
Please list and describe any significant injuries, illnesses or major operations along with the dates:
Has vision been examined?*
- 是
- 否
Date*
MM slash DD slash YYYY
Results*
Has hearing been examined?*
- 是
- 否
Date*
MM slash DD slash YYYY
Results*
Please list any medication your child is taking along with the reason it was prescribed:

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Child's Developmental History
Please Note When Each Occurred. Please put N/A if not applicable:
Babbled:*
Fed Self:*
Sat:*
Gestured:*
Bladder Control:*
Crawled:*
Spoke first word:*
Bowel Control:*
Walked:*
Put words together:*
Dressed self:*
Slept through the night:*
Hand preference:*
- Right
- Left
- Swaps
Was your child bottle fed? Any problems?
Does your child have any problems with exaggerated gag reflex?
Did or does your child have any problems eating?

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Child’s Educational Details
Name of pre-school:*
Frequency:*
Attended since:*
Name of current school:*
Frequency:*
Attended since:*
Please fill in Grade OR Year your child is in:*
School System*
- IB (Year)
- American (Grade)
- Australian (Year)
Does your child receive additional support at school? If so, what type, how often and from whom?*

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Child’s Play and Behaviour Details
How well does your child play with other children/peers?*
What are your child’s favourite play activities/ interests?*
Please describe your child’s behavior/ mood at home:*
Please describe your child’s behaviour at school:*

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Child’s Family History
Please enter the name and age of each sibling:
Siblings
姓名年龄
Please list any other people living at home and their relationship to your child:
姓名 Relationship
Please list all languages spoken at home:*
What is your child’s native language?*
Has anyone in the family ever had a history of any developmental, learning or mental health difficulties?

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Additional Information
If your child requires therapy, what are your personal goals/expectations?
Please note any other information which you consider to be relevant:
签名
Guardian's Name Signing*
第一页后一页
签名*
请在框内使用鼠标或触屏设备手指签名。
Untitled

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预约

请致电前台人员（+852）2807 2992，或填写下面的快速咨询表格，治疗师将回电给您。

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皇后大道中110-116号
中环
香港

(852) 2807 3223

central@spot.com.hk

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One Island South 10层 1021-25室
香叶道2号
黄竹坑
香港

(852) 2807 2992

contact@spot.com.hk。

SPOT 愉景湾

6层604室
愉景湾广场南广场（A座）
大屿山愉景湾
香港

(852) 2807 3223

central@spot.com.hk

SPOT 九龙湾

EASTMARK 15层1501室
常悦道21号
九龙湾
香港

(852) 2807 0800

kowloon@spot.com.hk

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