Occupational Therapy Screen Parent Questionnaire
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
Date
Parent / Guardian completing form
*
First Name
Last Name
Today's date
 -
Month
 -
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Reason(s) for requesting a screen:
*
Concerns about motor development
Concerns about sensory integration / regulation
Concerns about general development
Recommended by treating therapist or physician
Just curious
Other
Please answer the following questions about your child, using the 5-point scale. Higher numbers indicate either higher agreement with the statement, or more intensity.
My child has difficulty with sleeping.
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5
0 is Less, 5 is More
My child has difficulty with transition times, such as waking up or changing from one activity to another when prompted.
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0 is Less, 5 is More
My child has difficulty with drinking from a cup or straw.
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0 is Less, 5 is More
My child has difficulty with feeding.
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0 is Less, 5 is More
I think my child was or is delayed meeting motor milestones, such as rolling over, sitting, crawling, standing or walking.
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0 is Less, 5 is More
My child did not crawl at all or only for a very short time.
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0 is Less, 5 is More
My child cries or used to cry when on their tummy to play.
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0 is Less, 5 is More
My child has difficulty using their hands effectively, such as when holding a bottle, spoon, or toys.
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0 is Less, 5 is More
My child falls often or bumps into things.
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My child doesn't help hold himself up when I hold him.
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My child needs to lean against things when sitting.
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My child seems to move without any caution, such as walking off of ledges or running into the street.
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My child is very cautious, sometimes more cautious than I would expect for their age.
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My child licks, chews, or bites herself, others, or nonfood objects.
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0 is Less, 5 is More
My child has been labeled or treated as a "behavior problem".
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My child ignores other children.
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My child doesn't respond to their name.
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My child seems to have difficulty finding an item among other objects, such as a favorite toy in a box, a particular color crayon, their shoes on the floor, or their cubby space at school.
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My child covers their ears in response to everyday sounds.
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My child spins or hangs upside down.
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My child seeks out messy things, such as playing in mud, soap, lotion, or peanut butter, or saliva.
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0 is Less, 5 is More
My child becomes upset when clothing, hands, or face are wet or messy.
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0 is Less, 5 is More
My child hesitates when walking across uneven surfaces or avoids play equipment such as swings.
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0 is Less, 5 is More
My child seems to always need to hold an item in their hands, or they keep their hands up or closed often.
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0 is Less, 5 is More
My child has/had colic or unexplained crying and sometimes needs a lot of help to calm.
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0 is Less, 5 is More
My child seems to overreact to small bumps or scrapes, crying louder and/or longer than expected.
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0 is Less, 5 is More
My child at times seems to be unaware of things that seem painful, such as hitting their head, shots, falls, or biting.
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My child has difficulty using two hands together, such as clapping, cutting, holding paper still while drawing, or catching a ball.
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0 is Less, 5 is More
My child prefers to play with toys the same way each time (i.e. lining up, putting into container/dumping out, unable to use items in pretend play to represent people or animals or human-like interactions) or doesn't seem to understand how to play with toys (i.e., throws everything).
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My child hates baths or having hair washed / brushed.
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0 is Less, 5 is More
My child seems to switch from one activity to another very quickly, with short attention.
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My child seems to hold things either very tightly or loosely.
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My child tries to control games or activities and may refuse to participate if they can't make the rules.
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My child's challenges create difficulty with: (please check all that apply)
Safety
Eating
Dressing
Hygiene
Bathing
Car rides
School
Homework
Toilet training
Outings, such as shopping or restaurants
Play (using imagination, building, using toys, etc.)
Social Interactions with other children
Interactions with adults
Other
Please share any other information you would like us to know about your child or family.
Submit
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