CHAMP1 Family & Science Conference

Therapist & Interview Information Form

Please provide the details below before your appointment at the 5th CHAMP1 Family & Science Conference in Rimini, Italy.

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CHAMP Personal Data

Name *

First

Last

Date Of Birth *

Sex *

Male
Female

Date of diagnosis *

Languages spoken by parents *

English
Italian
French
Spanish
German
Other:

Other languages spoken (Parents) *

Clinical Picture

Please answer the below about your CHAMP at their current age.

Intellectual disability - IQ

Not yet evaluated
IQ higher than 70
Mild (IQ 55-70)
Medium (IQ 40-55)
Severe (IQ <40)

Presence of other pathologies? *

Other Pathologies: *

Please provide more detail

Behavioural difficulties? *

None
Aggressive behaviors or strong angry outbursts when frustrated or upset
Self-harming behaviours (e.g. biting, hitting)
Eats or puts inedible objects in the mouth
Engages in repetitive behaviours (e.g. rituals, stereotypies)
Other

E.g. autism / ADHD / anxiety / oppositional traits

Behavioural difficulties: *

Please provide more detail

Hypersensitivity to:

Sound
Light
Heat
Cold
Physical Contact
Pain
Other

Other hypersensitivity: *

Please provide more detail

Hyposensitivity to:

Sound
Light
Heat
Cold
Physical Contact
Pain
Other

Other hyposensitivity: *

Please provide more detail

Sleep disorders? *

Sleep disorders: *

Please provide more detail

Respiratory disorders? *

Respiratory disorders: *

Please provide more detail

Epilepsy? *

Epilepsy: *

Please provide more detail and name of medications

Recurrent headaches? *

Yes
No
Unable to answer

Recurrent headaches *

Please provide more detail, e.g. frequency

Therapies & Support

Please answer the below about your CHAMP to help us build a picture of the support they received before and after their diaagnosis.

Physiotherapy *

Before diagnosis
After diagnosis
Not received

Speech therapy *

Before diagnosis
After diagnosis
Not received

Psychomotricity *

Before diagnosis
After diagnosis
Not received

AAC (Augmentative Alternative Communication) *

Before diagnosis
After diagnosis
Not received

Behavioural therapies *

Before diagnosis
After diagnosis
Not received

Behavioural therapies *

Please provide more detail on which types of behavioural therapies.

Psychotherapy or Psychological Support *

Before diagnosis
After diagnosis
Not received

Educational support *

Yes - School
Yes - Home
Yes - Other
Not received

Other interventions? *

e.g. hippotherapy, music therapy, art therapy.

Other interventions: *

Please provide more detail

Feeding & Swallowing

Please answer the below about your CHAMP at their current age.

Feeding Ability *

Can feed self using cutlery
Can feed self using hands
Assisted by caregiver
PEG fed
Nasogastric tube

Feeding & Digestion abnormalities *

Dysphagia (Problems with swallowing)
Oro-facial hypotonia (Weak oral muscles)
Sialorrhea (dribbling)
Coughing (do the cough frequently while eating?)
Aversion to food (Refusal of certain flavours, textures, shapes or colours)
Delay in the feeding stages
Constipation
GERD (gastroesophageal reflux)
Cyclical vomiting (recurrent vomiting)

Communication & Language

Please answer the below about your CHAMP at their current age.

Languages spoken/understood by CHAMP *

English
Italian
French
Spanish
German
Other:

CHAMP languages: *

Current verbal communicative abilities *

Non-Verbal
Minimally verbal (Only speaks some words)
Verbal with articulation difficulties (difficulty in pronunciation)
Morphosyntactic difficulties (difficulty producing sentences)
Verbal without difficulties (correct age of onset of speech)

How many words can your CHAMP1 speak? *

What age did your CHAMP begin using verbal communication? *

Speech therapy frequency *

Multiple times a week
Weekly
Monthly
Sporadic
No therapy but under supervision
Not performed

Communication methods *

Verbal
AAC - Tablet
AAC - PECS
AAC - Communicator
AAC - Visual agenda
AAC - Gestures
AAC - Sign language
AAC - Other

What other AAC device? *

Language comprehension *

Doesn't understand language
Understands single words
Understands simple sentences
Understands moderate sentences
Understands complex sentences

Autonomy

Please answer the below about your CHAMP at their current age.

Do they help with small household chores and/or to tidy up toys? *

Do they sit at a table? *

e.g. are they able to stay in a structured activity?

How long will they stick to the activity? *

Can they navigate a familiar environment? *

e.g. home, school, families houses

School

Please answer the below about your CHAMP at their current age.

Do they attend school? *

Full time or part time? *

Full time
Part time

Do they have support teacher/teaching assistance? *

Full time or part time? *

Full time
Part time

Are there other educational figures present? *

What other figures?

Full time or part time? *

Full time
Part time

What are the main problems to manage that they encounter in daily school life?

Motor Skills

Please answer the below about your CHAMP at their current age.

Feeding & Drinking

Can they feed themselves? *

Yes
No
Sometimes

Can they use a spoon correctly? *

Yes
No
With help

Can they use a fork correctly? *

Yes
No
With help

Can they use a knife and fork together correctly? *

Yes
No
With help

Can they drink from a glass without spilling it? *

Yes
No
Sometimes

Can they pour water into a glass without spilling it? *

Yes
No
Sometimes

Can they peel fruit? *

Yes
No
Sometimes

Dressing and Undressing

Can they take off their shoes? *

Yes
No
With help

Can they take off their socks? *

Yes
No
With help

Can they take off their jacket? *

Yes
No
With help

Can they take off their t-shirt? *

Yes
No
With help

Can they take off their trousers/leggings? *

Yes
No
With help

Can they take off their underwear/nappy? *

Yes
No
With help

Can they put on their shoes? *

Yes
No
With help

Can they put on their socks? *

Yes
No
With help

Can they put on their jacket? *

Yes
No
With help

Can they put on their t-shirt? *

Yes
No
With help

Can they put on their trousers/leggings? *

Yes
No
With help

Can they put on their underwear/nappy? *

Yes
No
With help

Do they know the appropriate clothes and accessories for the day, climate or occasion? *

Do they correctly orient clothes? (front/back; right/left)? *

Yes
No
With help

Do they correctly distinguish the right shoe from the left? *

Can they undo buttons? *

Yes
No
With help

Can they undo velcro? *

Yes
No
With help

Can they fasten velcro? *

Yes
No
With help

Can they do up buttons? *

Yes
No
With help

Can they unzip zips? *

Yes
No
With help

Can they zip up zips? *

Yes
No
With help

Can they untie shoelaces? *

Yes
No
With help

Can they tie shoelaces? *

Yes
No
With help

Hygiene and Bathing

Can they wash their hands? *

Yes
No
With help

Can they wash their face? *

Yes
No
With help

Can they brush their teeth? *

Yes
No
With help

Can they brush their hair? *

Yes
No
With help

Do they wear a nappy/pad/diaper? *

Are they continent during the day? *

Yes
No
Partial

Are they continent during the night? *

Yes
No
Partial

Do they clean themself after urinating? *

Yes
No
With help

Do they clean themself after deficating? *

Yes
No
With help

Do they shower autonomously? *

Yes
No
With help

Do they use soap in the shower? *

Yes
No
With help

Do they rinse themself in the shower? *

Yes
No
With help

Do they wash their hair in the shower? *

Yes
No
With help

Do they dry themself with a towel? *

Yes
No
With help

Fine Motor Skills and Bimanual Coordination

Please answer the below about your CHAMP at their current age.

Can they use scissors? *

Yes
No
With help

Can they open and use glue sticks? *

Yes
No
With help

Can they use a pencil/pen? *

Yes
No
With help

Can they colour a drawing without going outside the lines? *

Yes
No
With help

Can they sharpen a pencil? *

Yes
No
With help

Can they play with plastercine? *

Yes
No
With help

e.g. pinch, separate and join pieces, make balls and rolls.

Can they use stickers? *

Yes
No
With help

e.g. peel off stickers and stick them on a sheet of paper.

Can they open bottles/jars? *

Yes
No
With help

Can they join multiple building blocks? *

Yes
No
With help

e.g. Duplo or Lego

Can they thread beads on a string? *

Yes
No
With help

Sleep and Rest

Please answer the below about your CHAMP at their current age.

Do they fall asleep by themselves? *

Yes
No
Sometimes

Do they sleep through the night? *

Yes
No
Sometimes

How many times do they wake per night? *

Do they fall back asleep by themselves? *

Yes
No
Sometimes

Do they take any medication or supplements to help them sleep? *

Yes
No
Sometimes

What medication or supplements do they take? *

Play and Leisure

Please answer the below about your CHAMP at their current age.

Do they initiate interactions with other children? *

Yes
No
Sometimes

Do they initiate interactions with other adults? *

Yes
No
Sometimes

Do they prefer to play alone or with others? *

Alone
With others

Do they play age appropriate games? *

Yes
No
Sometimes

If given a game, will they play it correctly? *

Yes
No
Sometimes

What games or activities do they enjoy the most? *

Home

Please answer the below about your CHAMP at their current age.

Do they collaborate in simple tasks at home? *

Yes
No
Sometimes

Packing away toys, setting the table, cleaning etc

What tasks? *

Additional Information

Please answer the below about your CHAMP at their current age.

Is there anything that particularly worries you about your child's autonomy?

What are the main challenges/difficulties to manage that they encounter on a daily basis

What do you expect from the Occupational Therapy process?

Is there anything else you think we should know?