Email
Name of child with Rett Syndrome
Age
Current Weight
Current Height
Who looks after the child during the day?
Current Care Team and contact details (doctors,therapists etc)
Current medication, dosages and supplements (e.g.Nexium for refl ux and Iliadin for nose)
Medical history/any surgical interventions/Current conditions/Medical concerns: Please stateany current medical concerns as well as past medical history and when it was diagnosed (e.g.Refl ux – June 2020)
Clinical Appearance: Are there any concerns with regards to your child’s appearance e.g. verydry skin, rash on tummy etc.
Gastro-intestinal health: What is your child’s bowel movements like e.g. mostly constipated,normal, 2 days/week very watery stools, frequent vomiting (daily up to 3 times) etc.
Sleep: How is your child sleeping and how many hours on average in 24 hours? Also indicate ifhe/she takes a daily nap E.g. waking every two hours at night and struggles to settle back tosleep etc. Go to bed at 8, up at 4 am.
Family history: Relating to direct parents – any allergies, Diabetes, High Blood pressure orcholesterol etc.
Have there been any previous attempts to make changes to your child’s diet (including anyprofessional input)? What did you do and for how long? How effective was it?
What are your specifi c CONCERNS with regards to your child’s health AND HIS/HER DIET?:
Have you got any concerns about your child's growth? e.g weight loss
Desired outcomes for the day:
Other: Specify
Please tell me about your child's daily routine.
Please describe how your child currently communicates with you
Has s/he ever used any symbols, photos or devices like a tablet or a computer tocommunicate and formulate messages? If yes please describe and bring the systems with you
Does your child follow a simple command or instruction? Or are there any behaviours thatsuggest she understands what is being said to her? Pls describe.
Does your child respond to yes/no questions? Pls describe.
Please list your child's favorite foods, toys/activities, tv shows, places to go.
Please tell us about any previous and current therapy intervention:
What is your child’s current mobility level? Walking/crawling/passive?
How much upper limb function do they have?
Does your child have any siblings? (older/younger? And are they willing/able to help with activities?)
Message
Send
