ST/OT/PT Parent Questionnaire

Child's Name

Today's Date

Sex

M F

Child's Birthday

Age

School

Grade

Address

City

Zip Code

Home phone

Referring Physician

Phone

Medical Diagnosis

Presenting Problem

Please explain your primary concerns for referring this child for evaluation (concerns, difficulties, questions).

How have these difficulties improved or deteriorated?

Does anything seem to help alleviate some of the problems or concerns this child experiences?

Is there anything that makes the problems or concerns worse?

How knowledgeable do you feel about the present concerns and difficulties?

Not Very Somewhat Very

Are there any areas about your child's need for OT/PT services that you'd like to know more about?

Family Structure

Parent/Guardian 1

Age

Occupation

Phone

My child calls me:

Parent/Guardian 2

Age

Occupation

Phone

My child calls me:

If other, please describe further.

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.

Down's Syndrome

Relation

Cancer

Relation

Diabetes

Relation

Food Allergies

Relation

Multiple Sclerosis

Relation

Seizures or Epilepsy

Relation

Tourette's Disorder

Relation

Neurofibromatosis

Relation

Attention Deficit Disorder

Relation

Speech or Language Problem

Relation

Fragile X Chromosome

Relation

Cystic Fibrosis

Relation

Hypoglycemia

Relation

Atmospheric Allergies

Relation

Muscular Dystrophy

Relation

Nervousness/ Anxiety

Relation

Asperger's Syndrome

Relation

Pervasive Developmental DIsorder

Relation

Depression

Relation

Mental Illness (Bipolar Disorder, Schizophrenia, Obsessive Compulsive Disorder, etc.)

Please specify type of mental illness and relation to child.

Other- describe.

Learning DIsorders

Reading

Handwriting

Speech/Oral Expression

Spelling

Math

Other

Pregnancy

If other, please specify.

Hospitalization during pregnancy?

Yes No

Reason?

X-ray during pregnancy?

Yes No

What month?

Was bed rest recommended?

Yes No

Please explain below.

Any Medications during pregnancy? If yes, please explain below.

Yes No

Prescription?

Yes No

Type and frequency.

Was the mother physically active? If no, please explain below.

Yes No

Please explain below.

Was the child very active in utero?

Yes No

Any exposure to smoke or alcohol? If yes, please explain below.

Yes No

Please explain below.

Pregnancy comments

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.

Labor/Delivery

Was this child born in a hospital?

Yes No

Was the baby:

Premature

Late

Full Term

Don't Know

How premature/ gestational age?

How late?

Length of labor

Birth weight

APGAR scores at birth:

At 5 min:

Check any of the following that occurred during birth:

Breech birth

Vaginal

Labor induced

Vacuum assist

Forceps

Cesarean Delivery

If Cesarean, was it:

Planned

Emergency

Explain if needed.

Were there breathing problems right after birth? If so, describe.

Supplemental oxygen?

Yes No

How long?

Neonatal Intensive Care Unit (NICU)? Explain.

Incubator: how long?

Jaundiced: Bilirubin count:

Very high

High

Just above normal

Bilirubin lights?

Yes No

How long?

Length of stay in hospital (mother)

days

Length of stay in hospital (child)

days

If child did not come home from hospital with mother, why?

Did the child have problems with eating?

Yes No

Explain.

Structural abnormalities? (cleft lip, etc.) Please explain below.

Labor/delivery comments and explanations.

Developmental Milestones: please note when each one occurred

Roll Over

Sit Alone

Crawl

Walk Alone

Drink from a cup

Feed Self

Stand Alone

Toilet Trained

Combined Words

What is the frequency of BMs?

Constipation or loose bowels

Constipated Loose

Stomach Aches?

Yes No

Has child experienced chronic ear infections?

Yes No

Age of onset

Frequency

Antibiotic type

Dosage

Tubes?

Yes No

Still occurring?

Yes No

Medication

Medication 1

Reason for taking

Dosage and frequency

Medication 2

Reason for taking

Dosage and frequency

Medication 3

Reason for taking

Dosage and frequency

Have there been any negative reactions to medications? If yes, please identify

Hospitalizations

Has your child ever been hospitalized?

Yes No

At what age?

Duration of stay

Please specify.

Surgeries

Has your child ever had a surgery?

Yes No

At what age?

Duration of stay

Please specify.

Childhood Illnesses/Injuries

Has the child had any serious accidents?

Yes No

Specify.

Has the child had any serious illnesses?

Yes No

Specify.

Please explain anything you checked above

Childhood Health

Occurence and location on skull.

Describe:

Please note the age/year for any checked above.

Please explain any item checked. Add the year and age it happened.

Childhood Development

Which hand does your child use for writing or drawing?

Which hand does your child use for eating?

Which hand does your child use for throwing, catching, etc.?

If your child uses both hands, which is most preferred?

How well did your child cut in Preschool/Kindergarten?

Poor Fair Good Excellent

How well did your child glue in Preschool/Kindergarten?

Poor Fair Good Excellent

How well did your child color in the lines?

Poor Fair Good Excellent

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

Difficulty learning how to ride a bike?

Yes No

Difficulty learning to skip?

Yes No

Difficulty following directions?

Yes No

Difficulty following multiple directions?

Yes No

If yes to any above, please describe

Hearing, Auditory, Balance, Coordination & Visual Processing

Have you ever noticed a problem with your child’s hearing?

Yes No

Describe:

Has your child ever had his/her hearing tested?

Yes No

If yes, date of test and results

Has your child ever had his/her vision tested?

Yes No

If yes, date of test and results

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

Good balance

Yes No

Good coordination

Yes No

Good handwriting?

Yes No

Clumsiness?

Yes No

Ability to perform the same physical tasks as age matched peers?

Yes No

Please describe any item above that was marked 'No'

Is your child participating in any social/community activities?

What sports does your child enjoy?

Hobbies?

What other activites does your child enjoy?

Does your child sleep through the night?

Yes No

On average, how long does it take for your child to fall asleep?

Please describe any concerns you have for your child’s sleeping habits or bedtime routine

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

Please indicate how your child relates to other children

Has problems relating or playing with other children?

Fights frequently with playmates?

Prefers playing with younger children?

Has difficulty making friends?

Prefers to play alone?

What role does your child take in peer group games? ( i.e. leader, aggressor, follower)

Please explain anything you checked above.

Developmental Team

Allergist's Name, Dates Seen and Findings

Audiologist's Name, Dates Seen, and FIndings

Developmental Optometrists Name, Dates Seen, and Findings

Gastroenterologist's Name, Dates Seen, and Findings

Neurologist's Name, Dates Seen, and Findings

Nutritionist's/Dietician's Name, Dates Seen, and Findings

Occupational Therapist's Name, Dates Seen, and Findings

Ophthalmologist's Name, Dates Seen, and Findings

Physical Therapist's Name, Dates Seen, and Findings

Psychiatrist's Name, Dates Seen, and Findings

Psychologist's Name, Dates Seen, and Findings

Speech Pathologist's Name, Dates Seen, and Findings

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