Parent’s questionnaire

Parent's Questionnaire

Name of Child

Date of birth of child

Name of person filling in questionnaire

Relationship to child

Preferred contact number

Home address

Email *

Section 2: Medical History

Your 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 weight

Was the pregnancy full term

If 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 prescribed

Section 3 Developmental milestones and abilities

Please 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):

Fine motor (manipulation of objects with hands):

Handwriting and colouring skills:

Favourite 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 heights

Is 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 appropriate

Does 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 age

Can do up buttons

Can put on socks

Can put on shoes

Can tie laces

Needs prompts to keep on task

lease 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 tasks

Reacts appropriately to external noise / distractions

Reacts appropriately to different textures

Appears 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 bouncing

Demonstrates self-control

Shows safety awareness as appropriate for their age

Uses personal space appropriately, does not intrude on space of others

Takes turns during games and activities

Does not get over-aroused; maintains controlled behaviour

Section 5: concerns

Using one word classifications (answers) of 'Yes', 'No' or 'Unsure' please indicate areas of concern for your child:

Fine motor

Motor weakness

Feeding

Dressing:

Play skills

Handwriting

Muscle tone

Endurance

Attention / Distractibility

Over / Under Active

Over Sensitive / Under Responsive

Sensory Processing

Toileting

Please 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: summary

Are 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 INFORMATION