Referring Physician Details
Name:*

Hospital/Clinic:*

Email:*

Contact No:*

Country:*

Patient Details
Name:*

Date of Birth:*

Gender:*

Male Female

Nationality:*

Nursery/School & Grade Name:*

Early Intervention Programme (If applicable)
Name:

Special Education:*

No Yes

Parent/Guardian Details
Name:*

Contact No:*

Email:*

Referring information
Please describe the reason for referral:*

Please select
Developmental Delay:*

Global Isolated Speech delay Motor delay Other domains

Autism Features: (e.g. lack of eye contact, lack of emotional reciprocity, repetitive stereotyped behavior, etc.)*

Genetic/ Neurologic Condition:
Diagnosed condition:*

No Yes Specify

Suspected condition:*

No Yes Specify

ADHD Symptoms: (e.g. difficulties sustaining attention, hyperactivity, impulsivity)*

Behavioural Difficulties ( Please Specify ):*

Sleeping Difficulties:*

School Difficulties Please specify: ( Kindly be informed that Cognitive assessment/IQ testing and psychoeducational assessments are NOT provided services )*

Other symptoms /concerns:*

Did the child lose any acquired skills? (e.g. loss of words)*

No Yes Specify

Stopped acquiring new skills?*

No YesSpecify

Is there any history of the following:
Self-Harm:*

No YesSpecify

Danger to others:*

No YesSpecify

Functional impairment due to symptoms:
Family Functioning:*

No YesSpecify

School Functioning:*

No YesSpecify

Relevant History
Previous Assessment/Evaluation:*

No Yes

Including:* Speech and Language Therapy Occupational TherapyClinical Psychology Educational Assessment (IQ testing)Psychiatry
KINDLY ADVISE PARENTS TO BRING ANY RELEVANT MEDICAL RECORD TO THE APPOINTMENT
Is this referral for second opinion?*

Yes No

Previous medical assessments and investigations? (please enclose/advise family to bring to the clinic visit)*

Non EEGBrain MRI Genetic testingHearing test Vision testOther

Hearing test: Yes No
Vision test: Yes No
Other:
Medical Conditions:*

No YesSpecify

Previous Surgeries:*

No YesSpecify

Hearing Test:*

No Yes

Vision Test:*

No Yes

Vaccinations up-to-date:*

No YesWhy?

MMR given:*

No Yes

List the medications the child is on or has been on previously (including herbal medications, alternative or complementary therapy)
Medication*
Dose*
Current?
Yes
Yes
Alternative/Complementary Therapy Specify:*

Speech & Language*

Yes No

Occupational Therapy*

Yes No

Behavioural Therapy*

Yes No

Physiotherapy*

Yes No

Other:*

YesNo Specify

Anything you would like to add Comments:*

Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai
United Arab
Emirates