CDER: CLIENT DEVELOPMENT EVALUATION REPORT

CDER: CLIENT DEVELOPMENT EVALUATION REPORT

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Date of CDER Evaluation

Client Last Name

Client First Name

Client UCI

Diagnostic Element

11. Intellectual Disabilities

12. Etiology

14. IQ Score

15. Intelligence Test

16. Adaptive Behavior Rating

Cerebral Palsy

17. Presence of Cerebral Palsy

18. Etiology

19. SEVERITY OF MOTOR DYSFUNCTION

20. TYPE OF MOTOR DYSFUNCTION

21. LOCATION OF MOTOR DYSFUNCTION

22. CONDITION IMPACT

AUTISM SPECTRUM DISORDER

23a. PRESENCE OF AUTISM SPECTRUM DISORDER

24. Etiology

25. Date of Diagnosis

26. CONDITION IMPACT

Epilepsy/Seizure Disorder

27a. Type of Seizure

27b. Seizure Frequency

27c. Condition Impact

28b. Seizure Frequency

28a. Type of Seizure

28c. Condition Impact

29b. Seizure Frequency

29a. Type of Seizure

29c. Condition Impact

30. Etiology

31. CLIENT TAKES ANTICONVULSANT MEDICATION

32. STATUS EPILEPTICUS

OTHER DEVELOPMENTAL DISABILITY

33. Other Disability:

YesNo

33a. Type of Other Disability

34b. Etiology

33b. Type of Other Disability

34b. Etiology

Risk Factor

35-47: (Summarize here)

PSYCHIATRIC DISORDERS

50a. Type of Psychiatric Disorder

50b.last evaluation

50c. Condition Impact

51a. Type of Psychiatric Disorder

51b.last evaluation

51c. Condition Impact

52a. Type of Psychiatric Disorder

52b.last evaluation

52c. Condition Impact

Chronic Major Medical Conditions

50a. Condition

50b.last evaluation

50c. Condition Impact

51a. Condition

51b.last evaluation

51c. Condition Impact

52a. Condition

52b.last evaluation

52c. Condition Impact

Skills Demonstrated in Daily Life

1. USING HANDS

2. WALKING

3. USING A WHEELCHAIR

4. TAKING PRESCRIPTION MEDICATION

5. EATING

6.TOILETING

7.BLADDER AND BOWEL CONTROL

8.PERSONAL CARE

9.DRESSING

10. SAFETY AWARENESS

11. FOCUSING ON TASKS AND ACTIVITIES

12. VERBAL COMMUNICATION

13. NONVERBAL COMMUNICATION

14. SOCIAL INTERACTION

Challenging Behaviors

15. DISRUPTIVE SOCIAL BEHAVIOR

16. AGGRESSIVE SOCIAL BEHAVIOR

17. SELF-INJURIOUS BEHAVIOR

18.DESTRUCTION OF PROPERTY

19. RUNNING OR WANDERING AWAY

20. Emotional Outbursts

Other Diagnostic Information

Hearing

60. Level of Hearing Loss Uncorrected

61. LEVEL OF HEARING LOSS CORRECTED

VISION

62. LEVEL OF VISION LOSS UNCORRECTED

63. LEVEL OF VISION LOSS CORRECTED

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