ST/OT/PT Parent Questionnaire

Please correct the errors described below.

Presenting Problem

Family Structure

Family Health

Many learning difficulties and emotional disturbances have a hereditary component. Have any family members had any of the following?

If yes, please specify family member's relationship to this child. If child is not residing with biological parents, please include health information on biological parents if known.


Please check your answers above and provide further details if required. Feel free to add anything else you think we should know about the pregnancy.



Developmental Milestones: please note when each one occurred




Childhood Illnesses/Injuries

Childhood Health

Childhood Development

From the age of five to the present time, were/are there any special problems noted in the following areas? If yes, please describe.

Hearing, Auditory, Balance, Coordination & Visual Processing

Does your child demonstrate the following qualities? If no, please describe.

Friendships: check all that apply, explain below any item you checked.

Developmental Team

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