Paediatric Functional Capacity Assessment Form

Consent Child’s Information - Full Name: Emily Johnson - Date of Birth: 15/04/2015 - Age: 8 years and 6 months - Gender: Female - NDIS Number: 123456789 - NDIS Plan Dates: 01/01/2023 - 31/12/2023 - NDIS Goals: Improve social skills, enhance fine motor skills, increase independence in daily activities - Immediate Family: John Johnson (Father), Sarah Johnson (Mother), Michael Johnson (Brother) Referral Information - Reason for Referral: Concerns about delayed fine motor skills and social interaction difficulties - Diagnoses - Primary Diagnosis: Autism Spectrum Disorder - Secondary Diagnosis: Sensory Processing Disorder - Paediatrician: Dr. Lisa Carter, contact: 555-1234 - Family History of Diagnoses: No known family history of similar conditions Medications - Current Medications: None - Medication Management: N/A Family Factors/ Informal Supports - Family Structure: Two-parent household with one sibling - Home Environment: Spacious home with a dedicated play area - Support Systems: Weekly occupational therapy, monthly family counseling - Relevant Family Dynamics or Stressors: Recent move to a new city - Current Living Environment: Detached house with backyard, both parents and one sibling reside Formal Supports - General Practitioner: Dr. Mark Lee, contact: 555-5678 - Paediatrician: Dr. Lisa Carter, contact: 555-1234 - Specialists: Dr. Anna Smith (Speech Therapist), contact: 555-8765 - Support Workers: Jane Doe, visits twice a week - Speech Pathology: Weekly sessions focusing on communication skills - Physiotherapy: N/A - Psychology: Monthly sessions for emotional regulation - Equine Therapy: N/A - Music/ Art Therapy: Weekly art therapy sessions Early Years / Developmental History - Pregnancy and Birth: - Full-Term: Yes - Complications: None - Developmental Milestones: - Sitting Independently: 8 months - Crawling: 10 months - Walking: 15 months - Talking (First Words): 18 months - Noted Observations of Delays: Delayed speech and social interaction noticed at age 3 Activities of Daily Living (ADLs) - Dressing: - Can the child dress themselves independently? No - Which types of clothing or fastenings are challenging? Buttons and zippers - Bathing: - Can the child bathe independently? No - Are there specific tasks (e.g., washing, rinsing) they struggle with? Rinsing - Toileting: - Is the child toilet trained? Yes - Do they need assistance with any aspects of toileting (e.g., wiping, handwashing)? Occasional assistance with wiping - Grooming and Hygiene: - Hair Brushing: No, requires assistance - Teeth Brushing: Yes, with supervision - Eating: - Can the child use utensils and feed themselves independently? Yes - Do they need help with meal preparation or eating (e.g., cutting food, handling utensils)? Assistance with cutting food Sleep - Sleep Hygiene/ Routine: Consistent bedtime routine, sleeps from 8 PM to 6:30 AM - Bedtime/ Waking: Occasionally wakes during the night - Sleep Quality: Generally good, with occasional disturbances - Medication Compliance: N/A Ability to Handle Changes in Plans and Routines - Response to Changes: Becomes anxious with sudden changes - Adaptability: Needs time to adjust to new situations Instrumental Activities of Daily Living - Household Chores: - Can the child assist with household chores (e.g., setting the table, cleaning up)? Yes, with guidance - Which chores can they complete independently? Setting the table - Managing Personal Belongings: - Can the child organise and manage their personal items (e.g., school supplies, clothing)? No, requires assistance - Money Management: - Is the child able to manage and use money (e.g., making purchases, understanding value)? No - Do they need assistance with budgeting or handling money? Yes, requires full assistance - Transportation: - Can the child use public transportation or travel independently? No - What kind of support do they need with transportation (e.g., navigating routes, safety)? Requires supervision and guidance School Performance and Participation - Performance and Engagement in the School Environment: - Classroom Behavior and Functioning: Struggles with attention and following instructions - Participation and Engagement: Engages with support, struggles with group activities - Additional Supports: Receives one-on-one support in the classroom Cognition and Communication - Executive Functioning: - Planning and Organization: Needs assistance with planning tasks - Problem-Solving: Requires guidance - Flexibility: Struggles with flexibility - Inhibition/Impulse Control: Needs support to manage impulses - Working Memory: Challenges with retaining information - Attention: - Sustained Attention: Limited attention span - Selective Attention: Difficulty focusing on relevant tasks - Divided Attention: Struggles with multitasking - Memory: - Short-Term Memory: Needs repetition to retain information - Long-Term Memory: Generally good - Episodic Memory: Can recall specific events with prompting - Semantic Memory: Good understanding of facts - Language and Communication: - Receptive Language: Understands simple instructions - Expressive Language: Limited vocabulary, uses gestures - Comprehension: Needs support to understand complex language Reasoning and Judgment - Logical Reasoning: Needs support to draw conclusions - Abstract Reasoning: Struggles with abstract concepts - Judgment: Requires guidance in decision-making Impressionability: Easily influenced by peers Social and Community Participation - Community Activities: Participates in weekly community playgroup - Social Skills with Familiar People: - Interaction with Family and Friends: Engages well with familiar people - Social Skills with Unfamiliar People: - Interaction with Strangers: Shy and reserved - Community Support: Access to local support groups Emotional Regulation/ Self-Regulation - Emotional Responses: Becomes frustrated easily - Self-Regulation Skills: Needs support to manage emotions - Emotional Regulation Strategies: Uses deep breathing techniques Behaviours of Concern - Types of Behaviours: Occasional tantrums, repetitive behaviors - Triggers and Patterns: Changes in routine, sensory overload - Impact on Daily Functioning: Affects participation in group activities - Coping and Management Strategies: Use of visual schedules, sensory breaks - Response from Others: Supportive responses from family and educators Revised NDIS GOALS: Enhance social interaction, improve fine motor skills, increase independence in daily tasks Recommendations: Continue occupational therapy, introduce social skills group, explore additional sensory integration therapy