PARENT/CARER QUESTIONNAIRE
Please complete and return this questionnaire before your appointment
Date: ____________ Child’s Name: ___________________ Date of Birth: _____________ Age:
__________ Address: _________________________ Phone: ________________________________
_________________________ Home Phone: ____________________________ City:
____________________________ Zip: ________ E-mail: ___________________
Does the child live with both parents? ___________ Mother’s Name: _____________________
Age: _________________ Mother’s Occupation: ________________________ Business
Phone:_______________
Cell Phone: ___________________ Father’s Name: _______________ Age: _________________
Father’s Occupation: ___________ Business Phone: _____________Phone:________________
Referred By: ________________________________ Phone: ______________________
Address:
_____________________________________________________________________________________
_____
ABOUT YOUR CHILD
What is your main concern?
When did you first notice difficulties?
Have you ever sought advice from an
SLT/OT/PT/EP before?
How was your child like a baby?
Anything significant that happened during
pregnancy? If so, Please share
Was it SVD, NVD or C- Section? If C section what
is the reason?
Describe the child’s speech-language problem?
Social/Interaction/Communication skills;
How does he/she communicate with
you/siblings/peers?
Eg. pointing, gesture, words.
Who lives at home?
Please age &
sex
What languages are spoken at home?
What is
his/her
dominant
language?
How does your child interact with other
children?
How does your child interact with adults?
Prenatal and Birth History;
Mother’s general health during pregnancy (Illnesses, accidents, medications, etc.)
Length of pregnancy:
General condition:
Circle type of delivery:
Head First Feet First Breech C-Section
Length of Labor:
Birth weight:
Were there any unusual conditions that may have affected the pregnancy or birth?
Developmental Milestones: Age
Neck holding
Roll over
Sitting
Crawl
Supported Walk
Pointing
First word
Walk without Support
Sentences
Toilet Trained
Use single words (e.g., no, mom, doggie, etc.): Please write child’s examples
Combine words (e.g., me go, daddy shoe, etc.):Please write child’s examples
Name simple objects (e.g., dog, car, tree, etc.):Please write child’s examples
Use simple questions (e.g., Where’s the doggie?, etc.): Please write child’s examples
Engage in conversation: Please write child’s examples, if you have...
Describe the child’s response to sound (e.g., responds to all sounds, responds to loud sounds only,
inconsistently responds to sounds, etc.).
Medical History;
Provide the approximate ages at which the child suffered the following illnesses and conditions:
Allergies Cold Dizziness Encephalitis
Asthma Tinnitus Measles Seizures
Tonsillitis Chicken pox Ear infection Headaches
Has the child had any surgeries? If yes, what type and when (e.g., tonsillectomy, adenoidectomy, etc.)?
Describe any major accidents or hospitalizations.
Is the child taking any medications? If yes, identify.
Have there been any negative reactions to medications? If yes, identify.
Educational History;
School Name, Grade & Teacher(s);
How is the child doing academically (or pre-academically)?
Does the child receive special services? If yes, describe.
How does the child interact with others (e.g., shy, aggressive, uncooperative, etc.)?
If enrolled for special education services, has an Individualized Education Plan (IEP) been developed? If
yes, describe the most important goals.
Behavioral Concerns/Social communication skills:
Does he show tantrums?
Is he/she seems to be frustrated
Is he/she is always in motion e.g., running,
jumping etc.
Does your child cry easily?
Is your child moody?
Shows difficulty in turn taking?
Shows difficulty in playing and making friends?
Is he/she fearful of new changes or situations?
Did you child exhibit any of the following behaviors before the age of 7?
Put a check (√ ) on those that apply. Also specify if a child exhibited the
behaviors sometimes, often or always.
☐ Didn’t pay attention to details
☐ Avoids swings
☐ Had trouble staying focused; was easily distracted
☐ Appeared not to listen when spoken to
☐ Had difficulty remembering things and following instructions
☐ Had trouble staying organized, planning ahead, and finishing projects
☐ Got bored with a task before it was completed
☐ Constantly fidgets or flaps hands
☐ Gets easily distracted by bright lights from the task he is doing
☐ Moved around constantly, often ran or climbed inappropriately
☐ Picky eater
☐ Had difficulty playing quietly or relaxing
☐ Was always “on the go,” as if driven by a motor
☐ Had difficulty in holding pencil or cutting skills
☐ Gets distracted by the sound of blender, vacuum, dryer etc.
☐ Likes to smell everything
☐ Couldn’t wait for his or her turn in line or in games
☐ Shows destructive play behavior
☐ Loves messy play
☐ Loves to hug others
☐ Had an inability to keep powerful emotions in check, resulting in angry outbursts of temper
tantrums
☐ Guessed, rather than took time to solve a problem
What do you hope will be achieved by this assessment?
Is there any further information you feel we should know about your child?
What kind of services are you looking for, 1. Speech Language Therapy
mention as much as your child requires? 2. Occupational Therapy
3. Behavior Therapy
How did you
hear about Word of Mouth
Gulberg
Family Clinic? Advertisement
Social Media
Website
Other ______________________
Disclaimer: The information that you have provided in the above questionnaire is confidential and will
not be disclosed to a third party without your consent and approval.
Thank You
