Disccount - Glenn Wesley

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Glenn Wesley Care Form

Basic Info
Communication & Interaction
Sensory & Emotional Responses
Cognitive & Learning Abilities
Behavioral Patterns

The information you provide helps us understand your loved one’s development and behavior.
Your answers support more accurate follow-up and personalized care.
All information is confidential.

Participant Information

Name or Alias

Age

Phone/Mobile

Communication & Interaction

Please indicate if the individual has ever been diagnosed with any of the following conditions.

Learns new words

Never

Sometimes

Always

Doesn't wish to answer

How often?

Number of times

Severity of the problem

He/She doesn’t look at who he/she’s talking to

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Does he/she speak?

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Echolalia (repeats phrases he/she hears)

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Makes new friends

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Hangs out with friends

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Speaks unfamiliar words

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

He/She is affectionate, kisses and/or hugs

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Asks about adult relationships or behavior

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Defies parental orders

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Misbehaves in society

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Aggressive with others

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Sensory & Emotional Responses

Please indicate if the individual has ever been diagnosed with any of the following conditions.

Noise bothers him/her

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes music

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Covers his/her ears with hands

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Hits his/her head with hands

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Doesn’t like to sleep alone

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Wakes up crying in the middle of the night

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Nightmares

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Nervous breakdowns

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Suicidal thoughts

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Fear of harmless objects

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Cries inconsolably

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Doesn’t rest when awake

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Cognitive & Learning Abilities

Please indicate if the individual has ever been diagnosed with any of the following conditions.

Difficulty understanding instructions

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Learns new words

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes mathematics?

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes arts

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes manual work

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Assembles and likes puzzles

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Makes strange poses

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Good athletic coordination

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Poor coordination running

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Difficulty to fall asleep

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Runs away from home

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Wakes up very early

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Behavioral Patterns

Please indicate if the individual has ever been diagnosed with any of the following conditions.

Likes to pile up things, toys, cups, etc.

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Oscillating repeated motions

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Plays by throwing things at the ceiling

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Breaks toys, TV controls, etc.

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Plays to destroy things

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Rotates objects

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Obsessive with what he/she wants

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

He/She doesn’t realize danger

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes to play with fire

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Makes verbal noises

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Screams loudly

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Messes up his/her family's things

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Eating & Physical Health

Please indicate if the individual has ever been diagnosed with any of the following conditions.

Has an apetite

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes to eat oranges, tangerines or mani

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes to eat meat, chicken and/or eggs

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Has gastrointestinal problems

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Takes controlled medication

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Has a scheduled surgery

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Allergic sinusitis

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Taste for sweets, cookies, and/or cereals

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

White at the corners of the lips

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Zeborrhea or scabs on the face

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Itchiness on head, arms and/or legs

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Itching in intimate parts

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Walks continously

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Self-Harm & Physical Reactions

Please indicate if the individual has ever been diagnosed with any of the following conditions.

Pulls out hair, nails, and/or others

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

He/She throws himself/herself to the ground to hit himself/herself

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Causes damage or bruises to himself/herself

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Agressive with close people

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Shakes or moves while sleeping

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Scratches his/her eyes, ears and/or nose

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Takes behavioral therapy

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Has Therapist or Teacher complaints

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Taste for new clothes or footwear

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Daily Routines & Preferences

Please indicate if the individual has ever been diagnosed with any of the following conditions.

Likes to shower

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Likes to sing

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem

Pointing with adult hands

Never

Sometimes

Always

Doesn't wish to answer

How often?

Numeric Field

Severity of the problem