Occupational Therapy Evaluation Questionnaire

Occupational Therapy Evaluation Questionnaire

The Speech, Language, and Learning Center of TN, LLC
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Caregiver's Name*

First NameLast Name
Date of Evaluation*

MonthDayYear

Is your child able to complete the following? Please choose one.*

	Yes	No	With some help
Toileting
Bathing
Brushing Teeth
Brushing Hair
Putting on/taking off shirt
Putting on/taking off pants
Putting on/taking off shoes
Fasteners (buttons,zippers,snaps)
Tying shoes (if age appropriate)
Self-feeding with utensils

Additional comments regarding independence in self-care activities:
Does your child demonstrate any difficulties with specific food textures, clothing textures, smells, visuals, sounds, etc.?*

YesNo
If yes, please explain:
Do you have any concerns with your child's behavior at home/school/daycare?*

YesNo
If yes, please explain:
If your child attends school or daycare, do you have any concerns regarding thier performance academically?*

YesNo
If yes, please explain:
If your child attends school or daycare, do you have any concerns regarding their behavior in this setting?*

YesNo
If yes, please explain:
Does your child wear glasses?*

YesNo
If yes, please explain in detail reason for glasses:
When was your child's last vision screen?

At what age did your child:*

Does your child experience any of the following issues:*

	Yes	No
Bed wetting past 5 years of age:
Poor balance:
Poor coordination:
Fatigues easily:
Lack of focus:
Anxiety
Regulating emotions:
Motion sickness:
Toe walking:
Poor posture in sitting:
Difficulty with sustained attention:
Difficulty with working memory:
Difficulty reading (if age appropriate):
Difficulty writing (if age appropriate):
Difficulty sitting still:
Difficulty with social play:
Communication:

Are there any specific things that your child enjoys or is interested in?
Do you have any other concerns or reasons for receiving an occupational therapy evaluation?
Should be Empty: