Parent Questionnaire Parent Questionnaire (Please complete the form to the best of your ability and return it prior to your evaluation appointment. The evaluating therapist will review this form and may probe for additional information during the evaluation. Please include copies of related evaluations/progress reports and/or current IEP’s). Specialized Therapy ServicesChild Name* First Last Date Of Birth* Date Format: MM slash DD slash YYYY Gender* Male Female Other EthnicityHome Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Family Information and BackgroundParent/Legal Guardian* First Last OccupationEmail Enter Email Confirm Email Cell Phone*Parent/Legal Guardian (Additional)* First Last OccupationEmail Enter Email Confirm Email Cell Phone*Current Marital Status Married Single Separated Divorced How old was the child when the separation occurred?How old was the child when the divorce occurred?Child's Pediatrician | Hospital/Office/Location | Phone Number | Fax Number*Other Members Of The Family: Relationship | Age | Speech/Hearing Problems*Any siblings living outside the home?*NoYesPlease provide the siblings Name | Relationship | AgePrimary language spoken in the home:*Other languages spoken by child or family. Is the child bilingual?Please provide any background information that may be relevant to this assessment (family stressors, illnesses, changes in routine, recent losses, etc)*Describe, in your own words, your child’s difficulties:*Developmental MilestonesPlease fill out, to the best of your knowledge, the month/year of age at which your child first accomplished the following:Turned OverStood (Alone) Sat Alone1st Word CrawledWalked (Alone) Babbled2 Words Together About how many words does your child say? 0-10 20-50 100-200 200+ My child uses the following to communicate (check all that apply) Words Gestures (reaching, pointing, etc.) Sign Language Device None Has there been a regression of skills in the last 3 months?*NoYesPlease explain....Does your child have a formal diagnosis?How would you describe the status of your child's health?*ExcellentGoodFairPoorMedically FragileHas your child ever received therapy? Check all that apply: Speech OT PT Music Therapy ABA Has your child had an official assessment?*NoYesWhere was the assessment made?Attach FIles Here Drop files here or Birth HistoryMother age at the time of pregnancy:Length of labor: Birth weight:Apgar score: Multiple births yes/noDid the mother recieve prenatal care? Please check mark all that occurred during the pregnancy: Difficulty with conception Convulsions Flu Frequent Use of Alcohol Use of non-prescription drugs X-Rays to abdomen Hypertension Accidents / Injury Frequent Hospitalizations Difficulty breathing Measles Toxemia Weight Loss Anesthesia RH Factor Emotional Problems Bleeding Nausea Please check all that apply that occurred during/at birth: Unusual / Hard Labor Induced Labor Breech C-Section Instruments used Nuchal Cord (cord around neck) Please describe any significant medical history ( I.e allergies, seizures, breathing difficulties, frequent colds, frequent ear infections, ear tubes, head injury, head injuries, vision/hearing problems, etc)Please list any medications your child takes regularly/& why:Please use the space below to elaborate/address concerns regarding the child’s behavior and development:Current Speech - Language - HearingHas anyone else in the family ever had a speech / language / literacy / learning difficulty?Has your child had a hearing test? If yes, when and results.....Does your child.......(check any or all that apply) Repeat sounds, words or phrases over and over? Understand what you are saying? Retrieve/point to common objects upon request (ball, cup shoe)? Follow simple directions (Get your shoes)? Respond correctly to yes/no questions? Respond correctly to who/what/where/when/why questions? Does your child combine words (red ball, give me)? Does your child speak in sentences? Please check all the behaviors that describe your child: Withdrawn Slow to learn Aggressive Shy Gives up easily Jealous Tires easily Talkative Clumsy Outgoing Follows rules Tantrums Leader Passive Please check all the behaviors that describe your child: Stubborn Hyperactive Follower Difficulty making friends Generally happy Difficulty sharing cooperative Easily frustrated/impulsive Restless Poor Eye Contact Easily distracted/short attention Self-injurious behavior Self-stimulating behavior Willing to try new activities Does your child’s play involve…… Independent Play (parallel play, i.e., child plays alone near other children) Pretend Play (imaginative play, e.g., using a block as a pretend phone) Cooperative Play (games, shared play) Feeding and DevelopmentDid/does your child have any feeding problems (e.g., vomiting, reflux, difficulty with sucking/swallowing) YES NO Explain:Did your baby transition easily to solid foods? YES NO Explain:Does your child now tolerate a range of food types and textures? YES NO Explain:Does your child frequently gag on solids? YES NO Explain:Did your child use a dummy/pacifier? YES NO What age did your child cease (completely) using it? If your child is currently using a dummy, how often is it used?Does your child have poor saliva control (e.g. drooling) YES NODo you have any concern for your child regarding the following?: Hand Dominance (e.g. swapping hands during tasks) Fine Motor Skills (using their hands and fingers e.g. holding a pencil, picking up small objects, etc.) Gross Motor Skills (big movements e.g. running, jumping, hopping, climbing, ball skills) Planning and organization (e.g. sequencing during daily activities) Sensory Issues (e.g. aversion or attraction to sound, touch, or specific items) Self-care (e.g. brushing teeth, dressing or toileting) If any of the above were checkmarked, please explain here:School ExperiencesIs your child of shcool age?*NoYesWhat school does your child attend and what grade?What educational difficulties have you observed in your child?Please list any outside interests or extracurricular activities that your child is involved in: List your child's personal strengths: SchedulingDoes your child take naps?*NoYesWhat are his/her nap times?Is your child potty trained?*YesNoWhat is your preferred location for therapy services?*KensingtonLiberty Station/Point Loma (Speech Only)No PreferenceWhat are your preferred times for therapy services?MORNING (8AM-11AM)EARLY AFTERNOON (11AM-1PM)LATE AFTERNOON (2PM-5PM)Please list availability and any other appointments/commitments that we should know before scheduling? *Please include dates/times