Parents Questionnaire

Which team member are you here to see?(Required)

Who referred you?

Date

Details about your child(Required)

Child's Name

Date of Birth/ Age

Sex

Contact details

Home address

Phone

School

Teacher

Grade

Adults with whom child is living

Natural mother

Natural father

Stepmother

Stepfather

Other

Non-residential adults involved with child

Natural mother

Natural father

Stepmother

Stepfather

Other

Please provide contact details for the Adult/s with whom the child is living

Name

Occupation

Bus. Name

Contact Details

Bus. Phone

Bus. Address

Bus. Email

Please provide contact details for the Adult/s with whom the child is living

Name

Occupation

Bus. Name

Contact Details

Bus. Phone

Bus. Address

Bus. Email

Please provide contact details for the Adult/s with whom the child is living

Name

Occupation

Bus. Name

Contact Details

Bus. Phone

Bus. Address

Bus. Email

Purpose of consultation (brief summary of the main problem):

Pregnancy (complications)

Complications

Excessive vomiting

Hospitalization required

Excessive staining or blood loss

Toxemia

Threatened miscarriage

Infection(s) (specify)

Operation(s) (specify)

Other illness(es) (specify)

Did you smoke during pregnancy? Average number of cigarettes/day

Other non-prescription drug use during pregnancy (Describe)

Prescription medications taken during pregnancy (Describe)

X-ray studies during pregnancy Duration (weeks)

Delivery

Type of labor:

Spontaneous

Induced

Duration of labor (hours)

Type of delivery:

Vertex (Normal)

Caesarean

Breach

Complications?

Birth Weight?

Appropriate for gestational age (AG)

Small for gestational age (SGA)

Post-Delivery Period (while in the hospital)

Respiration

Immediate

Delayed

If delayed, how long?

Cry

Immediate

Delayed

If delayed, how long?

Suck

Strong

Weak

Mucous accumulation

Immediate

Apgar score (if known)

Untitled

Vomitting

Diarrhea

Untitled

Jaundice

Incubator Care

Infection (specify)

Birth defects (specify)

Infancy-Toddler Period

Were any of the following present to a significant degree during the first few years of life? If so, describe.

Colic

Frequent headbanging

Did not enjoy cuddling

Was not calmed by being held and/or stroked

Excessive number of accidents compared to other children

Excessive restlessness

Developmental Milestones

Please note if each milestone occurred Early, At the Normal Time, or Late, to the best of your recollection.

Smiled

Early

At the normal time

Late

Sat without support

Early

At the normal time

Late

Stood without support

Early

At the normal time

Late

Walked without assistance

Early

At the normal time

Late

Spoke first words besides "ma-ma" and "da-da"

Early

At the normal time

Late

Said phrases

Early

At the normal time

Late

Said sentences

Early

At the normal time

Late

Bowel trained, daytime

Early

At the normal time

Late

Bowel trained, nighttime

Early

At the normal time

Late

Bladder trained, daytime

Early

At the normal time

Late

Bladder trained, nighttime

Early

At the normal time

Late

Rode tricycle

Early

At the normal time

Late

Rode bicycle (without training wheels)

Early

At the normal time

Late

Buttoned clothing

Early

At the normal time

Late

Tied shoelaces

Early

At the normal time

Late

Named colors

Early

At the normal time

Late

Said alphabet in order

Early

At the normal time

Late

Began to read

Early

At the normal time

Late

Coordination: Rate your child on the following skills:

Walking

Good

Average

Poor

Running

Good

Average

Poor

Throwing

Good

Average

Poor

Catching

Good

Average

Poor

Shoelace tying

Good

Average

Poor

Buttoning

Good

Average

Poor

Writing

Good

Average

Poor

Athletic abilities

Good

Average

Poor

Comprehension and understanding

Do you consider your child to understand directions and situations as well as other children his or her age?

Yes

If not, why not?

How would you rate your child's overall level of intelligence compared to other children?

Below average

Average

Above average

School (Rate your child's school experience related to academic learning)

Kindergarten

Good

Average

Poor

Primary School

Good

Average

Poor

Intermediate School

Good

Average

Poor

College/Secondary

Good

Average

Poor

To the best of your knowledge, at what grade level is your child functioning:

Arithmetic

Spelling

Reading

Has you child ever had to repeat a year?

Yes

If yes, please explain why?

Present class placement

Regular class

Special class

If they are in a special class, please explain why

Kinds of special therapy or remedial work your child is currently receiving

Describe briefly any academic school problems

School (Rate your child's school experience related to behavior: Good Average Poor)

Kindergarten

Primary

Intermediate

Current Grade

Does your child's teacher describe any of the following as a significant classroom problem?

Doesn't sit still in his or her seat

Frequently gets up and walks around the classroom

Shouts out; doesn't wait to be called upon

Won't wait his or her turn

Does not cooperate in group activities

Typically does better in a one-to-one relationship

Doesn't respect the rights of others

Doesn't pay attention during storytelling

Describe briefly any other classroom behavior problems

Peer Relationships

Does your child seek friendships with peers?

Is your child sought by peers for friendship?

Does your child play primarily with children his or her own age?

Younger

Older

Describe briefly any problems your child may have with peers

Home Behaviour

All children exhibit, to some degree, the kinds of behavior listed below. Check those that you believe your child exhibits to an excessive or exaggerated degree when compared to other children his/her age.

Interests and accomplishments

What are your child's main hobbies and interests?

What are your child's areas of greatest accomplishment?

What does your child enjoy doing most?

What does your child dislike doing most?

Medical History

If your child's medical history includes any of the following, please note the age when the incident or illness occurred and any other pertinent information.

Childhood diseases (describe any complications)

Operations

Hospitalizations for illness(es) other than operations

Head injuries

With unconsciousness

Without unconsciousness

Convulsions

With fever

Without fever

Coma Meningitis or encephalitis

Persistent high fevers

Immunization reactions

Eye problems

Ear problems

Poisoning

Present Medical Status

Present height

Present weight

Current Illness(es) for which child is being treated

Medications child is taking (dosage?)

Family History-Mother

Age

Age at time of the patient's conception

Number of previous pregnancies

School

Learning problems (specify)

Medical problems (specify)

Have any of mother's blood relatives (not including patient and siblings) ever had problems similar to those your child has?

Family History-Father

Age

Age at time of the patient's conception

School

Learning problems (specify)

Medical problems (specify)

Have any of father's blood relatives (not including patient and siblings) ever had problems similar to those your child has?

Siblings

SIBLINGS

Name

Date of Birth/Age

Medical, Social or learning problems

Click on the plus + symbol to add multiple siblings

List names and addresses of any other professionals consulted about your child:

Names

Addresses

Click on the + symbol to add multiple names and addresses

ADDITIONAL REMARKS

Please use the remainder of this page to write any additional comments you wish to make regarding your child’s difficulties:

Would you like a copy of this form emailed to you?

Yes

Which email address should we send the form to?