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PARENT QUESTIONNAIRE

Download Printable PDF Form
Dear Parent or Guardian,
I look forward to meeting you and your child and evaluating your child's cognitive/neurologic development as requested. Your answers on this questionnaire will help me understand your child's health, neurologic functioning, learning skills, and behavior. Please list your concerns and provide all information you feel may be relevant.

Similar questionnaires are enclosed for you to give to your child and to your child's teacher or school counselor to complete.
Thank you very much.
Childs Name
Birthdate
Relationship to Child
Address
  City  State Zip
Home Phone
Work Phone
School Name
Grade
Teacher Name/Phone
What are your concerns, questions, and goals regarding your child's learning, development, neurologic functioning, and/or behavior? (Feel free to attach additional pages if necessary.)
What made you decide to obtain this evaluation?

GENERAL HEALTH HISTORY
Please check any of the following which were (or are) true for your child:
Pregnancy Problems:
Please Explain:
excessive maternal weight gain
failure to gain weight
excessive vomiting
excessive bleeding
exposure to medication(s)
exposure to alcohol
exposure to cigarettes
exposure to other substances
prior miscarriages or premature births
Birth History:  
premature birth
prolonged birth (>12 hours)
difficult delivery or C-section
twins, placenta abruption, or placenta praevia
birth injury
baby needed resuscitation
breathing problems
heart, skin, kidney, or other organ problems
jaundices
seizures
spina bffida
other
neurologic problems unusual features Infection
If you checked any of the above please explain:
Birth Weight
Length of stay in Hospital

Medical History:
Does your child take any medications? Yes No
If yes, list below
Name of Drug Dose
Has your child ever:  
had surgery?
been hospitalized?
been exposed to poison/overdose?
been injured seriously?
Has your child had problems with:  
eyes/vision
ears/hearing
heart
lungs
abdomen
kidneys/genitals/bladder
immune infection
musdes/bones/foints
neurologic function
seizures
headaches
floppiness/stirmess
balance problem
coordination problem/clumsiness
weakness
endurance problem
loss of consciousness/head trauma
meningitis/encephalitis
involuntary movements
muscular dystrophy
spina bifida/mentngomyelocele
other neurologic problem
Please give further details about any problem you checked above. (Attach additional page if necessary.)
Does your child have any allergies to medications? Yes No
Has your child had chickenpox? measles? mumps? rubel!* roseola?
Are your child's immunizations up to date? Yes No

DEVELOPMENT HISTORY
At approximately what age did your child begin to:
sit alone
Crawl
walk alone
walk up stairs
ride a tricycle
play ball/throw and catch
use two or more words together
speak dearly
feed self
with which hand?
dress self

hold a pencil well
write
Overall, how old a child does your child seem like now?
Were you ever concerned about your child's language, social, or motor development? Yes No

PERSONALITY/BEHAVIORAL HISTORY:

The following is a list of a wide variety of issues which may be of concern. Please check the appropriate column for this child for each issue.
  Average For Age/Not A Problem More Than Average/ Somewhat Problematic Significant Problem Or Concern
Sadness/Depression
Anxiety/Worry
Low Setf-EsteenVConfidence
Variable Moods
Easily Frustrated
Easily Angered/Irritable
Crying/Tantrums
Aggression/Fighting
Defiance/Disobedience
Destructive Behavior
Truancy/Running Away
Lying Or Stealing
Rejection By Peers/Unpopular
Gets Teased
Teases Others/Cruelty
Isolation/Loneliness
Passive Behavior/Eager To Please
Shyness/Mistrust
Clowning/Acting Out/Disruptive
Pesters Others
Manipulative/Controlling
Frequent Pains/Physical Complaints
Accident Prone
Acts Without Thinking
Hurries Through Tasks
Short Attention Span
Misses Key Information
Easily Distracted
Daydreams
Says Irrelevant Things
Daytime Sleepiness/Easily Fatigued
Easily Bored/Restless
Difficult To Satisfy
Fidgety/Overly Active
High Energy Level
Variable Performance (Unpredictable Quality Of Work/Inconsistent Grades)
Eating Or Appetite Problems
Sleep HaMs/tnsomnia/Sleepwalks
Wets Or Soils
Head-Bangs/Other Self-Injurious Behavior
Rocks/Other Repetitive Habits
Hordes Things
Repetitive Acts/Compulsions
Sees Or Hears Things That Are Not There
Uses Drugs Or Alcohol
Sudden Twtehes/Blinks/Ncds
Unusual Grunts Or Other Sounds
Difficulty Giving Or Receiving Affection
Inflexible/Difficulty With Changes
Do you have any other concerns about personality, emotional, or behavioral functioning? Yes No
Feel free to explain any of your responses more fully.

SCHQOL HISTORY
Please describe your child's current school placement (grade and type of class)..
Does your child receive any special help now in or out of school, and rf so, what kind and how often?
Did your child previously receive any special help? Yes No
Has your child had any previous evaluations? Do you know or have the results? If you have copies of these evaluations, please bring them along with you to your appointment. Also, please bring report cards and samples of schootwork if possible.
speech/language evaluation Yes No
achievement tests Yes No
psychological evaluation or 1Q tests Yes No
psychiatric evaluation Yes No
neurologic evaluation Yes No
physical/occupational evaluation Yes No
Did your child attend preschool? Kindergarten? Yes No
Was your chad ever retained a grade? Yes No
Please rate your child's skills in the following areas:

ACADEMIC PERFORMANCE:

  Weakness Compared To Others Average Strength Compared To Others
Speech/Language:      
Pronunciation
Stuttering
Understanding Others
Hearmg/Usterung
Other
RMdtng:      
Aloud
Silently
Reading Rate
Recognition Of Words
Phonics
Comprehending What Was Read
Remembering What Was Read
Spelling:      
Accuracy
Consistency
Writing:      
Legibility/ Coordination
Remembering Letter Shapes
Punctuation
Sentence Structure/Organization
Sophistication OF Ideas
Mathematics:      
Understanding The Question
Remembering How To Do The Problem/Basic Skids
Word Problems/ Applications
History/Social Studies
Science
Foretqn Language
About how much time a week do you spend working with this child on homework, reading, etc.
Do you have any other concerns about academic skills/development?
Feel free to explain any of your responses more fully.

STUDY STRATEGIES/OTHER CHARACTERISTICS:

  Weakness Compared To Others Average Strength Compared To Others
Speech/Language:      
Rate/Keeping Up
Identifying Key Concepts
Concentration/Attention
Comprehension Of Orally/Aurally Presented Material
Comprehension Of Written/Visually Presented Material
Study fig:      
Memorization
Organization
Allowing Appropriate Trne
Concentration
Assignment*
Attention To Instruction
Comprehension Of Task
Checking Work
Allowing Appropriate Tfne/Uvng Appropriate Books And Supplies
Completion Of Task
Response To Feedback
Consistency Of Performance
T**t Taking:
AnxJety/Chofcinq Up
Pacing/Organization
Recall Of Facts
Consistence Of Performance
Class Participation:
Attention/Staying On Subject
Enthusiasm/Curiosity
Social Skills
Other
Talking In Class
Leaving Seat/Disruptive
Bothering Others
Athletic Ability
Imagination/Creativity
Sense Of Humor
Flexibility/Acceptance Of New Ideas
 
Do you have other concerns about study strategies/other characteristics?
Feel free to explain any of your responses more fully.
FAMILY AND SOCIAL HISTORY:  
What sports or hobbies does your child enjoy?
Is your child involved in any organized activities (team sports, scouts, etc) Yes No
Any pets? Yes No
Who does your child live with? (Please list names and ages of household members)
Child’s Mother’s Name
Age
Education
Occupation
Significant health problems