not interfering with his / her having a limited impact on interfering with functioning in has disabled him / her in all functioning in other life functioning in one other life more than one life domain or other life domains. domains or this information domain (self care, social is disabling in at least one is unknown to me / does not interaction, communication, domain. apply. etc). If the needs / functioning fall within a shaded box, explain why: child’s C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-12. Medical Needs Treatment Involvement (PAST 30 DAYS) – Child and family are actively Child and / or family are Child and / or family are Child and / or family are involved in treatment or this generally involved in generally uninvolved currently resistant to all is not applicable or this treatment but may struggle although they are efforts to provide medical information is unknown to to stay consistent. sometimes compliant with treatment. me / does not apply. recommendations. If the needs / functioning fall within a shaded box, explain why: child’s III-13. Medical Needs Intensity of Treatment (PAST 30 DAYS) – medical treatment Childs medical treatment treatment is daily but medical treatment is Child’s Child’s Child’s involves taking daily involves taking multiple non-invasive. Treatment daily and invasive and medications or visiting a medications or visiting a can be administered by a requires either a medical medical professional no medical professional caregiver. professional or trained more than weekly, or this multiple times per week. caregiver to administer. information is unknown to me / does not apply. If the needs / functioning fall within a shaded box, explain why: child’s III-14. Medical Needs Organizational Complexity (PAST 30 DAYS) – All medical care is provided medical care is medical care medical care Child’s Child’s Child’s by a single medical generally provided by a requires collaboration of requires the collaboration of professional or this coordinated team medical multiple professionals who multiple professionals who information is unknown to professionals who work for work for more than one work for more than one me / does not apply. the same organization. organization. organization and are not able to communicate effectively. If the needs / functioning fall within a shaded box, explain why: child’s
not interfering with his / her functioning in other life domains or this information is unknown to me / does not apply. having a limited impact on functioning in one other life domain (self care, social interaction, communication, etc). interfering with functioning in more than one life domain or is disabling in at least one domain. has disabled him / her in all other life domains. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-12. Medical Needs – Treatment Involvement (PAST 30 DAYS) Child and family are actively involved in treatment or this is not applicable or this information is unknown to me / does not apply. Child and / or family are generally involved in treatment but may struggle to stay consistent. Child and / or family are generally uninvolved although they are sometimes compliant with recommendations. Child and / or family are currently resistant to all efforts to provide medical treatment. If the child’s needs / functioning fall within a shaded box, explain why: III-13. Medical Needs – Intensity of Treatment (PAST 30 DAYS) Child’s medical treatment involves taking daily medications or visiting a medical professional no more than weekly, or this information is unknown to me / does not apply. Childs medical treatment involves taking multiple medications or visiting a medical professional multiple times per week. Child’s treatment is daily but non-invasive. Treatment can be administered by a caregiver. Child’s medical treatment is daily and invasive and requires either a medical professional or trained caregiver to administer. If the child’s needs / functioning fall within a shaded box, explain why: III-14. Medical Needs – Organizational Complexity (PAST 30 DAYS) All medical care is provided by a single medical professional or this information is unknown to me / does not apply. Child’s medical care is generally provided by a coordinated team medical professionals who work for the same organization. Child’s medical care requires collaboration of multiple professionals who work for more than one organization. Child’s medical care requires the collaboration of multiple professionals who work for more than one organization and are not able to communicate effectively. If the child’s needs / functioning fall within a shaded box, explain why:
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