Confidential Parent Questionnaire

Confidential Parent Questionnaire

(All information provided is strictly confidential and will not be provided to any other agency without your written consent.)
Child's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
I. General Information
Describe what concerns you have about your child's development:*
When did you first notice this problem:*
List any diagnoses your child has and the professional who made the diagnosis (include dates):
Has your child received any previous treatment for this specific problem?*

YESNO
If yes, where/when:
Is a second language spoken in the home:*

YESNO
If so, what language:
Please list other persons living in your home, their ages, and relationship to child: *
What do you hope to learn from this evaluation and what specific questions do you have or areas do you wish to address? *
II. Developmental History
A. Prenatal
How was the health of the mother during this pregnancy?*
Any accidents or illnesses?*

YESNO
If yes, explain:
Has the mother had any problems with other pregnancies before or after this?*

YESNO
If yes, explain
Please check any conditions that applied to the mother during this pregnancy:
Did the mother take any medication or drugs during this pregnancy?*

YESNO
If yes, what:
B. Peri-natal
Weight of Child at Birth: pounds, ounces
Duration of pregnancy:
Were instruments used: YES    NO      If yes, what:
Was the delivery: Spontaneous    Induced   Cesarean    Breech
Was there anything unusual in the baby’s condition at birth or soon after, such as:  Injury   Cord wrapped around neck    Bruises    Jaundice    Blue coloring  Other
Was the baby given blood transfusions or exchanges at birth?YES    NO
Was the baby given oxygen? YES    NO
Were there any problems after birth? YES    NO
If yes, Feeding Problems Other Illness, Explain
Was baby released from hospital with the mother? YES    NO
If no, when?
III. Health History
Check any illnesses the child has had. Specify information, such as age, degree of temperature, medical treatment received:*
Please elaborate on anything checked above:
If you child has had more than one ear infection, how old was the child when the ear infections occurred?
How were the ear infections treated:
Check any surgery your child has had. Specify date of surgery, where, duration of hospitalization, and attending physician:
Tonsillectomy
Adenoidectomy
Ear Surgery, any type
Orthopedic surgery, any type
Cardiac surgery, any type
Other surgery
Is the child presently on medication? YES NO *
If yes, specify name and reason prescribed: *
Does any member of the family have similar problems that the child has? YES   NO
If yes, describe who and what was the problem
Is child allergic to food, drink, insect bites, etc:YES    NO
If yes, explain
IV. Development
A. Motor/Sensorimotor
At what age did your child:
Please describe any differences you noticed in your child’s motor development from other children at the same age:
Please describe any assistive equipment your child uses:
What movement activities does your child like?
What activities does your child avoid?
Does your child have issues with muscle tone or range of motion? If yes, describe
Does he/she seem overly sensitive to:

Being touchedBeing huggedHaving face washedHaving hair cutEating certain foodsWearing certain clothes
Does he/she:

Avoid touching thingsAvoid getting dirtyCover ears to certain noisesBlink excessively when a ball is thrown to them
Can your child:

Throw a ballCatch a ball
Which hand is used most often?
Do you feel your child’s hand skills are delayed? Please list the hand skills you feel are difficult for him/her to do:
B. Self Help

Please indicate whether your child CAN or CANNOT do the following with respect to eating:

	YES	NO	UNSURE
Suck from bottle/straw
Hold and drink from cup with sipper top
Finger feed
Hold a spoon
Stab with a fork
Eats with little to no spilling
Drink from a cup held for him/her
Hold and drink from a cup without a top
Feed self without help
Scoop with spoon
Use a knife to spread/cut

Describe any help needed for feeding:

Please indicate if your child CAN or CANNOT do the following with respect to dressing:

	YES	NO	UNSURE
Removes shoes
Removes pants
Puts on shoes
Puts on pants
Puts on a belt
Tie Shoes
Removes shirt/jacket
Removes underpants
Puts on shirt/jacket
Button shirt
Zip jacket

Describe any help needed for dressing:

Please indicate if your child CAN or CANNOT do the following with respect to toileting:

	YES	NO	UNSURE
Obtaining and using supplies
Maintaining a toileting position
Cleaning body
Caring for incontinence needs
Managing clothing
Transferring to and from toileting position
Caring for menstrual needs
Completing intentional control of bowel movements and urination

Describe any assistance required for toileting:

Please indicate whether your child CAN or CANNOT do the following with respect to bath/shower:

	YES	NO	UNSURE
Obtaining and using supplies
Soaping
Rinsing
Drying body parts
Maintaining bathing position
Transferring to and from bathing positions

Describe any assistance required for bathing:

Please indicate what child CAN or CANNOT do with respect to hygiene:*

	YES	NO	UNSURE
Obtaining and using supplies
Using lotion
Washing, drying, combing, styling, brushing
Caring for nails
Applying deodorant
Brushing teeth

Describe any assistance required for general hygiene:

With respect to Instrumental Activities of Daily Living (IADLs), please check whether your child CAN or CANNOT do the following:

	YES	NO	UNSURE
Financial management (utilizing money, card, or debit card
Meal prep and cleanup
Utilizing a microwave

With respect to safety and emergency, please indicate if your child CAN or CANNOT do the following:

	YES	NO	UNSURE
Knowing and performing preventative procedures to maintain a safe environment
Recognizing sudden, unexpected hazardous situation
Initiating emergency action; calling 911
Identifying emergency contact numbers (mom, dad, home, 911)

C. Psychological/Play Development
Does your child have difficulty:

Have difficulty paying attentionHave difficulty sticking to one activity for 3-4 minutesHave difficulty sticking to one activity for 15-20 minutesHave difficulty switching tasksHave rituals (doing the same thing in the same way each time)Become easily frustratedHave trantrumsHit/Bite
Describe any other behavior problems you have with your child:
What disciplinary methods do you use?
Does your child have many friends?
Does he/she prefer to play with older children? Younger children? Alone?
What are your child’s favorite play activities toys, games etc.?
Does your child enjoy or do any of the following:

Looking at booksPut toys in mouthRough and tumble playBang toys togetherRole playingAct out familiar routinesMake-believe playUse objects appropriatelyGames with rules
Does your child have unusual fears? Preoccupations?
Has he/she had any evaluations for behavioral or emotional problems? If so, by whom and when?
Please check any that apply to your child:

ShyFriendlyCooperativeCreativeNervousOverly talkativeJealousThumb suckerNail biterDestructiveAngryAggressiveRitualisticRocksHead bangerPoor tolerance for changeBitesFidgetyAffectionateShort attention spanLazyOverly activeAbsent mindedLacks self confidenceCuddlerPicky eaterPoor appetiteRarely shows emotionDaydreamsAvoids eye contactLooks through youGood self esteem
Is the child/Does the child:

Responsive to peopleEat wellMost responsive to objectsSleep wellEspecially alert to movementsMake his wants knownSensitive to vibratory sensationsCry, sob, shed tearsSensitive to being touchedShow concern when separated from parentsHighly distractible, hyperactiveLaugh, smile, seem happyBehavior consistent from day to dayRock his head in crib, or while sitting or standingPlayful with children, adults, pets“Bang” his head on crib, chair, floor“Stare” at lights, objects, people, into space
V. Feeding History
Does or did your child have difficulty with any of the following:

Sucking/nursingRegurgitation of liquids or solids through noseTransition from bottle to baby foodDifficulty chewing or swallowingChoking or gaggingHistory of aspirationRefluxTube feeding (NG, OG, or g-tube)
Is your child a picky eater:

YESNO
If yes, explain. What food textures do they prefer or avoid:
VI. Speech-Language Development
What is/are his/her most frequent means of communication:*

gesturessoundswordsphrasescomplete sentenceslooking at objectspointing to objectsphysical manipulation
How old was your child when he/she used his/her first meaningful word, other than “mama”/“dada”?    What was the word?
Does s/he have difficulty pronouncing any sounds? YES    NO
If so, which ones?
Can parents understand his speech? YES    NO
Relatives? YES    NO
Playmates? YES    NO
Teachers? YES    NO
Is your child easily frustrated when he/she is not understood? If so how does he/she express that frustration?
Is your child aware of his/her communication difficulties?
At what age did your child:
VII. Hearing/Vision
Do you suspect any hearing difficulty?   Yes   No
Has your child’s hearing been tested?   Yes   No   If yes, When      Where?      Results?
Has your child been diagnosed with a hearing impairment?   Yes   No   If yes, by whom and when      Please describe hearing loss that has been diagnosed:
Do you think he hears your voice?   Yes   No   How do you know?
Does he know from which direction sounds come?     Yes   No
Does he hear better with one ear than the other?   Yes   No
How do you get the child’s attention when his back is turned away?
Can your child understand directions/and or conversation:   Yes   No   If “no”, what behaviors have you observed?
Has your child been diagnosed with an auditory processing disorder?   Yes   No
VIII. Educational History
Name of school presently attending: *
Grade or level: *
Describe general progress and behavior in school: *
Does your child have an IEP:*
If yes, please upload below:

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Is the child in special class or receiving tutoring for any reason? If so, specify where and for what reason:
Does your child display preference for any learning style over another? Visual, auditory, both?
Does your child receive any therapies currently:*
If yes, please describe and provide therapist names, etc.
Has your child received therapy in the past?*
If yes, please upload any pertinent evaluations or therapy notes:

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IX. Additional Parent Comments
Please provide your personal observations relative to the child’s speech/language/hearing, motor skills, and/or behavior: *
Completed by:*
Relationship to Client:*
Email*
example@example.com
Date*

MonthDayYear
Should be Empty:

Confidential Parent Questionnaire

I. General Information

II. Developmental History

A. Prenatal

B. Peri-natal

III. Health History

IV. Development

A. Motor/Sensorimotor

B. Self Help

C. Psychological/Play Development

V. Feeding History

VI. Speech-Language Development

VII. Hearing/Vision

VIII. Educational History

IX. Additional Parent Comments