Please enable JavaScript in your browser to complete this form.Parent's QuestionnaireName of ChildDate of birth of childName of person filling in questionnaireRelationship to childPreferred contact numberHome addressEmail *Section 2: Medical HistoryYour impressions and opinions of your child's abilities and comparative difficulties are very important in a complete assessment of your child. Could you please complete this questionnaire adding additional comments as necessary. If you do not know the answer to a question or it is irrelevant to your child, feel free to leave the question blank. Press submit at the bottom of the page when completed. Your assistance is appreciated and this information will be treated as confidential at all times.Birth weightWas the pregnancy full termIf not - how many weeks was it?Please describe any important illnesses, injuries or surgeries your child has had:-Current medical diagnoses / conditions: (ADHD, Autism, CP etc):Current medication prescribedSection 3 Developmental milestones and abilitiesPlease indicate the approximate age at which your child:Raised head:Rolled:Sat alone:Crawled on hands and knees:Pulled to stand:Stood alone:Walked:For the next three questions, using the one word classifications (answers) of 'Advanced', 'Normal' or 'Slow' what is your general impression of your child's motor development?Gross Motor (Running, jumping, ball play):AdvancedNormalSlowFine motor (manipulation of objects with hands): AdvancedNormalSlowHandwriting and colouring skills:AdvancedNormalSlowFavourite indoor play:Favourite outdoor play:In your opinion, what are your child's strengths?General behaviour:Using the one word classifications (answers) of 'Never', 'Sometimes', 'Usually', Always' or 'Unsure' what is your general impression of your child's general behaviour?Does your child tire easily during activities?Does your child appear fearful of movement or heightsIs your child impulsive?Is your child easily upset by failure?Is your child able to relate to peers?Is your child negative about their own ability?Is your child able to organise themselves and their belongings?Does your child have difficulty making friends?Does your child's behaviour appear the same at home and school?Can your child feed themselves? (age appropriateDoes your child have a good appetite / eats all food groups?Is your child a messy eater?Are food preferences determined by texture, taste, smell?Is independent for ageCan do up buttonsCan put on socksCan put on shoesCan tie lacesNeeds prompts to keep on tasklease list any toilet / washing / personal hygiene difficulties (bath, shower, teeth brushing, toileting)Section 4 sensory:Using the one word classifications (answers) of 'Never', 'Sometimes', 'Usually', Always' or 'Unsure' what is your general impression of your child's sensory behaviour?Transitions smoothly between tasksReacts appropriately to external noise / distractionsReacts appropriately to different texturesAppears to recognise objects by touch, manage small objects (eg buttons)Appears to sense where head and body are in space (move without falling or running into objects)Maintains postures (sitting or standing without slumping, fidgeting or bouncingDemonstrates self-controlShows safety awareness as appropriate for their ageUses personal space appropriately, does not intrude on space of othersTakes turns during games and activitiesDoes not get over-aroused; maintains controlled behaviourSection 5: concernsUsing one word classifications (answers) of 'Yes', 'No' or 'Unsure' please indicate areas of concern for your child:Fine motorMotor weaknessFeedingDressing:Play skillsHandwritingMuscle toneEnduranceAttention / DistractibilityOver / Under ActiveOver Sensitive / Under ResponsiveSensory ProcessingToiletingPlease describe any of these concerns that have been checked and detail any other concerns about your child that you may have:What would you like us to help you and your child with?Is your child currently receiving any therapy or involved in any special programs?What other evaluations, therapy or special programs has your child had in the past?Section 6: summaryAre there any other concerns or comments you feel would be helpful for us to understand your child better?PLEASE USE THIS SPACE FOR ANY ADDITIONAL INFORMATIONThank you very much for your time and effort. Please click the submit button.Submit