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GENIUS FACTORY ACADEMY FORM
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GENIUS FACTORY ACADEMY FORM
Genius Factory Academic
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GENIUS FACTORY ACADEMY FORM
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Student information
Student Name
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Date of Birth
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Chronological age
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Nationality
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Gender
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Female
Male
Parents' information
Layout
Father's name
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Mother's name
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Father's job
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Mother's job
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Father's phone number
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Mother's phone number
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Address
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Address Line 1
City
State / Province / Region
Email
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Email
Confirm Email
Emergency Phone Number
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Medical history
Medical history
Is the student's health condition generally not good?
Was the gestational age abnormal (9 months)?
Is the student exposed to problems immediately after birth
Was the student's developmental history abnormal (crawling, sitting, walking)?
Is the student suffering from congenital problems (internal or external)
Did the student suffer from a lack of oxygen during childbirth
Did the student stay in the hospital after giving birth?
Does the student have problems with vision, hearing or touch?
Does the student suffer from breathing problems?
Does the student suffer from infectious skin diseases?
Does the student suffer from epilepsy or convulsions?
Does the student have movement problems?
Does the student suffer from eczema?
Does the student suffer from any allergies to food, drinks, or others?
Does the student suffer from sleep problems?
Does the student suffer from a lack of control over the output (urine - feces)
Does the student take any medical medications?
Self care
Does the student struggle to go to the bathroom alone?
Does the student struggle with how to ask for the bathroom
Does the student suffer from the use of signs or pictures to request the bathroom?
Does the student suffer from nappy wear?
Does the student struggle to get dressed alone?
Does the student struggle to undress alone?
Does the student struggle to wear shoes or socks alone?
Does the student suffer from taking off the shoe or sock alone?
Does the student struggle to close the zipper alone?
Does the student suffer from locking buttons alone?
Does the student struggle to wear pants alone?
Does the student struggle to wash hands and face alone?
Does the student suffer from brushing his teeth alone?
Does the student suffer from using the towel or handkerchief (Tisho) alone?
Does the student suffer from combing the hair alone?
Does the student struggle to prepare food alone?
Does the student struggle with eating alone?
Does the student suffer from the demand for food and drink?
Other Items
What hand does the student use?
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What are the students' favorite reinforcers?
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Sensory disorders
Does the student suffer from frequent hand flapping?
Does the student suffer from frequent walking on the tip of the foot?
Does the student suffer from excessive sensitivity to loud sounds?
Does the student suffer from intense attention to weak and monotonous sounds?
Does the student suffer from a fondness for lights?
Does the student suffer from excessive physical contact such as cuddling?
Does the student suffer from discomfort from physical contact such as cuddling?
Does the student suffer from a lack of desire to wear clothes?
Does the student struggle to see things sideways?
Does the student suffer from bringing things closer to the eye and staring at them?
Does the student suffer from fear of swings or games that spin quickly?
Does the student suffer from self-harm or others?
Does the student suffer from incomprehensible sounds and tones?
Does the student have difficulty chewing food?
Is the student having difficulty swallowing food?
Does the student suffer from hypersensitivity to pungent smells?
Does the student suffer from excessive smelling of all things?
Does the student suffer from eating non-edible items?
Does the student suffer from stereotyping and daily routines?
Does the student suffer from fear of risks?
Speech and language disorders
Does the student have the ability to tell a complex story?
Can the student tell a simple story?
Does the student have the ability to draw conclusions?
Can the student form a sentence of 4-5 words?
Can the student form a sentence out of three words?
Can the student form a sentence out of two words?
Can the student pronounce a single word?
Can the student repeat the sentences?
Can the student repeat the words?
Can the student repeat the sounds?
Can the student understand a sentence of three words?
Can the student understand simple commands such as (stand - sit - come).
Can the student understand complex commands such as (bring a pen and color with it)
Can the student express what he wants through a sentence of three words
Can the student express what he wants through single words?
Can the student express what he wants through body language and signs
Can the student know his name when asked what is your name?
Can the student know his address and phone number when asked about it?
Can the student make eye contact with the speaker for 5 consecutive seconds?
Can the student pay attention when his name is called?
Can the student distinguish one sound from many overlapping sounds?
Is the student able to pay attention to something audible and visual?
Behavioral problems
Does the student suffer from ADHD or Attention Deficit Hyperactivity Disorder?
Is the student suffering from attachment to electronic screens?
Does the student suffer from stubbornness or failure to obey orders?
Does the student suffer from aggression and love of violence?
Does the student suffer from throwing things on the ground?
Does the student suffer from throwing himself on the ground?
Does the student suffer from sabotaging and breaking things?
Does the student suffer from finger sucking?
Is the student suffering from spitting on others?
Does the student suffer from self-biting behavior or others?
Does the student suffer from bedwetting?
Does the student suffer from any sexual disorders?
Does the student suffer from excessive crying and screaming?
Does the student suffer from revealing his private parts in front of others?
Does the student suffer from the inability to express the need for a bathroom?
Does the student noticeably suffer from talking to himself?
Does the student suffer from fear of strangers, animals, or other things?
Does the student suffer from fear of heights, elevators, or other things?
Does the student struggle to remain isolated alone from others?
Does the student suffer from binge eating?
Does the student suffer from a lack of desire for food?
Does the student suffer from taking things (that are not his right) without asking for permission?
Does the student suffer from lying and constant arguing?
Does the student suffer from biting nails?
Is the student experiencing bullying?
Does the student suffer from acute mood swings?
Is the student suffering from dependence on others?
Does the student suffer from excessive jealousy?
The strengths of the student from the point of view of the parents
Basic need points from the parents' point of view
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