Name of Client:

If someone other than the client is completing the form, please state name and relationship to client:

Email:

Home Address:

Emirates ID: (jpg/png)

Developmental History

As far as you are aware did you meet all developmental milestones on target?

Do you have any difficulties with co-ordination?

Are there any everyday activities you have difficulty with?

Have you ever had difficulty with the following areas prior to today?

Please check/tick the box as appropriate:
speech pronunciationmathematicsgross motor skillsunderstandingattention difficultyfine motor skillsexpressingsocial interactionhearing lossreadingwritingstutteringmemoryproblem solvingother

If the answer to any of the above is yes, please describe: .

Diet

Do you have any difficulties eating or drinking?

Do you have a healthy diet?

What food do you eat/enjoy?

What food do you dislike/avoid?

Medical History

Health

Family Doctor:

Contact Details:

if yes please provide the name and the dosage:

if yes please provide the name and the dosage:

Hearing

Do you have a hearing impairment?

Have you any concerns about your hearing?

Do you wear/need a hearing aid?

To the best of your knowledge do you:

Vision

Do you have any visual difficulties?

Do you wear/need glasses?

Are you concerned about your eyesight?

To the best of your knowledge do you:

Therapy

Have you ever been referred to any of the following specialists? (tick/check those that apply)
AudiologistOtolaryngologist (ENT)gross motor skillsunderstandingGastroenterologistSpeech & Language TherapistPsychologistOptometristPsychiatristPsychomotor TherapistNeurologistOther

if yes please provide the name and the dosage:

Educational History

Please tick/check as appropriate
Primary/Elementary SchoolSecondary/High SchoolUndergraduatePost Graduate

Degree(s):
Name of Institution/s for highest education levels only:

Work History

Occupation/s:

Place/s of Employment:

Most recent job duties:

Please describe any other factors you think may be relevant

Thank you for completing this form. Please submit this form to Stars for Special Abilities who will then contact you for
an appointment at the earliest available opportunity.

The information contained in this form is confidential and will not be distributed without your consent. Please be
sure to provide any relevant reports and information prior to your appointment.

We look forward to working with you.

Thank you.