Respite care form –  information update for your child

SPOKEN LANGUAGES AT HOME:

EnglishFrench

LAST NAME OF SOLIDARITÉ MEMBER:

FIRST NAME OF SOLIDARITÉ MEMBER:

ADDRESS:

DISTRICT:

PHONE:

EMAIL:

LAST NAME OF THE CHILD WHO WILL BE ACCOMPANIED DURING THE RESPITE:

FIRST NAME OF THE CHILD WHO WILL BE ACCOMPANIED DURING THE RESPITE:

DATE OF BIRTH:

DIAGNOSIS:

1. DOES HE/SHE HAVE EPILEPSY? YesNo

IF YES,

- WHAT ARE THE SIGNS THAT THE CHILD IS HAVING A SEIZURE?

- HOW OFTEN DOES THE CHILD HAVE SEIZURES?

- HOW LONG DOES AN AVERAGE SEIZURE LAST?

- WHAT SHOULD WE DO ABOUT SEIZURES?

- WHEN SHOULD WE MAKE A 911 CALL?

2. DOES HE HAVE ANY ALLERGIES? YesNo

- IF SO, TO WHAT AND DOES HE HAVE AN EPIPEN?

3. IS THE CHILD TAKING ANY MEDICATION? YesNo

- IF SO, WHICH ONE(S) AND WHAT IS THE DOSAGE?

4. HOW DOES YOUR CHILD COMMUNICATE?

- IF VERBALLY, DOES HE/SHE COMMUNICATE NORMALLY, USING SINGLE WORDS OR SHORT SENTENCES?

- IF NON-VERBALLY, DOES HE/SHE USE PICTOGRAMS, HAND HOLDING OR SIGN LANGUAGE?

5. WHAT IS THE CHILD'S MOTOR SKILL LEVEL?

- DOES HE/SHE HAVE DIFFICULTY WITH GLOBAL MOTOR SKILLS? FOR EXAMPLE, WALKING UP AND DOWN STAIRS, WALKING LONG DISTANCES, RIDING A BIKE?

- DOES HE/SHE HAVE DIFFICULTY WITH FINE MOTOR SKILLS? FOR EXAMPLE, WHEN DRAWING OR DOING CRAFTS?

- DOES HE/SHE HAVE A COORDINATION PROBLEM AFFECTING MOTOR SKILLS, FOR EXAMPLE, WHEN DRESSING, ETC.?

- WHAT PHYSICAL ASSISTANCE DOES YOUR CHILD REQUIRE FOR TRAVELLING? DOES YOUR CHILD HAVE A WHEELCHAIR?

6. HOW INDEPENDENT IS HE/SHE IN PERSONAL HYGIENE? DOES HE/SHE WEAR DIAPERS?

7. IS THERE ANYTHING PARTICULAR ABOUT HIS/HER DIET?

8. WHAT TIME DOES HE/SHE WAKE UP AND GO TO BED DURING THE DAY AT HOME?

9. AT WHAT TIME OF DAY DOES YOUR CHILD EAT?

10. WHAT IS HIS/HER BEDTIME ROUTINE AT NIGHT?

11. WHAT ARE HIS/HER INTERESTS, WHAT DOES YOUR CHILD LIKE?

12. WHAT ACTIVITIES AROUND YOUR HOME IS YOUR CHILD INTERESTED IN?

13. WHAT IS HIS/HER GENERAL BEHAVIOR?

14. IS HE/SHE AWARE OF DANGER?

15. CAN HE/SHE SWIM?

16. WHAT PRECAUTIONS SHOULD BE TAKEN AT HOME?

17. WHAT PRECAUTIONS SHOULD BE TAKEN WHEN GOING OUT?

18. DO YOU HAVE ANY OTHER CHILDREN AT HOME? YesNo
- IF SO, WHAT ARE THEIR DATES OF BIRTH?

19. DO YOU HAVE ANY PETS AT HOME? YesNo

- IF YES, PLEASE SPECIFY.

20. DO YOU HAVE ANY OTHER COMMENTS YOU’D LIKE TO ADD ABOUT YOUR CHILD OR ANYTHING ELSE?