Professional Documents
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DATE:
DEMOGRAPHIC DATA:
Name:
Age
Date of
Birth
Gender
Male
Diagnosis
Language delay
Address
Ref MD
Reason for
IE
Fathers
Name
Occupation
Mothers
name
Occupation
OT in
charge
Schedule
Friday 1:00-2:00
Saturday 2:00-3:00
BACKGROUND INFORMATION
Chief Complaint: According to his mother, Hindi pa siya nakakapagsalita. Nagwawala siya kapag hindi
nasusunod ang gusto.
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Birth Hx
Prenatal
This was the mothers first pregnancy and first child. Not until the 5th month of conception the mother
did realized her pregnancy. Subsequently, she got regular check-ups and took vitamins. The mother
also encountered two minor accidents obtaining minimal bruises but without causing vaginal
bleeding. Maternal infection such as UTI was also noted.
Perinatal
Kyrie was born at full term with a weight of ___lb., to a then ___y/o G1P1 (F1P0A0L1) mother via
caesarian section delivery. No significant complication during delivery.
Postnatal
The patient was discharged quickly from the hospital without any jaundice but had later
hospitalization for 3 days with convulsion. A complete vaccination was noted
Social
Informa
tion
Primary
Caregiver
Housing
Primary Language
Tagalong/ English
Family
School
N/A
Behavior Observation
Comments
Self Stimulating
Lining up of toys
Relates to : People/Object
Motivated
Fearful
OT Initial Evaluation
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Birth Hx
Prenatal
This was the mothers first pregnancy and first child. Not until the 5th month of conception the mother
did realized her pregnancy. Subsequently, she got regular check-ups and took vitamins. The mother
also encountered two minor accidents obtaining minimal bruises but without causing vaginal
bleeding. Maternal infection such as UTI was also noted.
Perinatal
Kyrie was born at full term with a weight of ___lb., to a then ___y/o G1P1 (F1P0A0L1) mother via
caesarian section delivery. No significant complication during delivery.
Easily distracted
He was able to follow and comply to some common and simple commands as to verbal and gestural with
moderate to minimal signs of hesitations and/or fear.
He was able to remain seated and wait for more than 15 minutes during on and off tasks.
He was observed to have fair impulse control as he tried to grab some toys presented to him.
Initiating a task was noted to be difficult for him depending on the familiarity of the task. He has fair attention
span but was able to finish a series of adult directed activities for around 5-10 minutes given prompts.
He was able to attend to the task and resist minimal to moderate amount of distractions.
In approaching simple activity, he appeared to be organized when instructed what to do and was able to pack
away the toys after the instruction.
As reported by his mother, he usually becomes frustrated whenever not given with things he wants and often
tends to throw tantrums.
OT Initial Evaluation
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SOCIAL-EMOTIONAL SKILLS
-
Kyrie was initially demonstrated crying behavior due to separation and stranger anxiety causing him not to
cooperate with the task. Eventually, as he was able to somehow regulate his emotion he was able to interact
and respond to the demand of the activity provided with physical and verbal prompts.
He demonstrated meaningful eye contact and has high consistency in responding to name calling.
He needs verbal and physical prompts to initiate and respond to interaction such as saying and gesturing hi
and goodbye etc.
Pointing and sharing of interest, emotion and affect were observed but reduced to some extent causing him to
have difficulty in this area of connecting to other people.
Difficulty of using verbal and non-verbal communicative behaviors was significantly noted.
Transitioning from different environment, persons and activities was a challenge for him due to difficulty with
adaptations.
OT Initial Evaluation
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Feeding/ Eating
-
Kyrie us able to indicate or express whenever he wants to eat and drink by gesturing and/or pointing. He can
do finger-feeding, and drink from a cup.
He is sometime spoon feed and when he eats by himself he tends to get untidy due to spillage.
Dressing
-
Kyrie is able to cooperate with donning and doffing his clothes, socks and shoes.
Toileting
-
OVERALL ASSESSMENT
Based from the clinical observation and assessment of the clients factors, Kyrie has difficulty in play, social
participation and ADL due to problems in working and play behaviors, social-emotional skills, sensory processing
skills, fine and gross motor skills and cognitive skills.
INTERVENTION PLAN
1.
To improve work behaviors necessary to support participation in play and ADL, Kyrie will:
a. Be oriented to different house rules such as that follows:
i. Listen
ii. Follow
iii. Sit nicely and wait
iv. Quiet mouth, hands and feet
v. Tap or ask teacher
vi. Use of visual support or icons to familiarize with the instructions
b. Complete/ finish one task before proceeding to another
c. Use kind firmness and modulated tone of voice when instructing him.
d. Refocus on task after getting distracted given 2-3 verbal prompts.
2.
To improve visual-perceptual and cognitive skills necessary to facilitate participation in ADL, play and social
activities, Kyrie will:
a. Form board puzzle with different concepts such as letters, numbers, fruits and shapes
b. Matching, sorting and recognizing colors, shapes, letters, numbers and common objects
c. Pointing and naming body parts to increase awareness
Kaleidoscope Therapy & Learning Center
OT Initial Evaluation
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d.
e.
3.
To improve fine motor skills necessary to support ADL, play and social participation, Kyrie will:
a. Manipulate snapping toys, surprise eggs, connecting toys, nuts and bolts etc.
b. Fixing puzzles with the components of turning, rotating and flipping the pieces of puzzle
c.
Stringing large and small beads
d. Shooting chips into the coinslot
e. Lacing boards
f. ADL boards (buttoning, zipping and connecting buckles)
g. Clay activities (cutting, rolling and poking)
4.
To improve gross motor skills, Kyrie will participate in the following activities:
a. Jumping on the trampoline
b. Going through the tires and tunnel
c. Wheelbarrow walk
d. Balancing on the beam and board
e. Climbing up and down the wall climber and stairs
f. Sliding down the slide pulling and pushing activities
5.
6.
7.
Parent Education:
Parents and family members will be educated with the proper use of behavior modification
techniques and language facilitation strategies. It is important to carry out the intervention program at home
and to other settings. Minimize the use of gadgets and TV is highly recommended but in case to be provided
make sure to supervise him. Avoid giving him food with high content of artificial sugar, preservatives and
additives. Provide a more structure environmental set-up at home.
RECOMMENDATION
Kaleidoscope Therapy & Learning Center
OT Initial Evaluation
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Kyrie is recommended to attend 2x a week individual OT intervention to manage the following concerns:
work behaviors, sensory processing, visual-perceptual skills, fine and gross motor skills, social interaction and ADL
skills.
For any suggestions, questions and comments regarding Kyriess report. Please feel free to contact the undersigned
therapist.
_________________________________
Mariella C. Vargas, OTRP
PRC Lic #: 0002970
Noted by:
___________________________
Monaliza Guce, OTR/L, OTRP
KTLC Center Director
OT Initial Evaluation
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