CR002 Parent Questionnaire

CLIENT INFORMATION

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Enrollment No. *

Child Name *

Gender *

Male

Female

Date of Birth *

Current Age *

Mother's Name

Father's Name

Mother's Occupation

Father's Occupation

Current Address

City

P.O. Box

Nationality

Home Phone

Mother's Mobile

Father's Mobile

Mother's Email

Father's Email

Who referred you for this evaluation?

Daytime Caregiver's Name

Languages Spoken at Home

Signature & Consent *

Signature

Print Name

Relationship to Child

Date

FAMILY INFORMATION

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Parents Status *

Married

Separated

Divorced

Who has custody of the child?

Siblings Information

Sibling Name	Age	Action

PARENTAL CONCERNS

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Main Concerns & Problems

Problem	Age Noted	Diagnosis & Clinician	Action

Other concerns about child's development or behavior?

Goals you would like to see your child accomplish

DEVELOPMENTAL HISTORY

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Developmental Milestones (approximate age)

Milestone	Age
Sat alone
Crawling/Creeping
Walking
Running
Babbling
First Words
Uses 2-word phrases
Dressing Self
Holds Bottle
Feeds self with spoon
Drinking from regular cup
Finger Feeds

Other Concerns or Information

DIAGNOSTIC INFORMATION

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Current Diagnosis

Date Given

Is this a firm diagnosis?

Yes

No

Diagnosed by (Name)

From (Hospital, Clinic, etc.)

Area of Specialty

Child's Pediatrician/Regular Physician

ASSESSMENT HISTORY

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Previous Assessments

Assessment Name	Date (Month/Year)	Results	Report Provided?	Action

MEDICAL HISTORY & TESTING

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Previous Medications

Medication	Dosage	Reason	Action

Current Medications

Medication	Dosage	Reason	Action

Significant Illnesses and Infections (approximate dates)

Surgeries and Hospitalizations (approximate dates)

Complications during childbirth?

Allergies (food and non-food)

Frequent ear infections? (List antibiotics used)

Hearing Test?

Yes

No

When & Results

Vision Test?

Yes

No

When & Results

CURRENT/PREVIOUS TREATMENTS & SERVICES

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Current Treatments & Services

Type of Service	Service Provider	Hours per Week	Start Date	Action

Previous Treatments & Services

Type of Service	Service Provider	Hours per Week	Start Date	End Date	Action

EDUCATION

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Present School

Grade

Location

Number of Hours per Week

Learning Support Assistant

Has child repeated a grade?

Yes

No

Comments

Receiving special education services?

Yes

No

Comments

RECEPTIVE LANGUAGE

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Primary language spoken at home

Other languages spoken at home?

Yes

No

Does child follow instructions without visual cues?

Yes

No

If yes, are instructions 1 or 2-step?

Instructions presented with or without cues?

Percentage of instructions child understands

Examples of instructions presented to child

EXPRESSIVE LANGUAGE - VOCAL COMMUNICATION

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Did child have speech that was lost?

Yes

No

If yes, was child ill at time of loss?

If yes, at what age did loss occur?

Child's usual means of communication

Verbal/Vocal Communication

Says what he/she wants

Non-Verbal/Non-Vocal Communication

Takes you to or points to what wants

Cries to let you know wants something

Augmentative Communication (device/pictures/icons)?

Yes

No

Does child babble or use vocal speech?

Yes

No

Does child use words for:

Imitation

Making requests

Making comments

In conversation

Words/phrases child uses

Average length of child's utterances

Problems with pronunciation/articulation?

Sounds unable to pronounce

How much family understands?

How much others understand?

Normal intonation or monotone?

Can child hold conversation about favorite topic?

SOCIAL BEHAVIOR

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Is child attached to anyone?

Yes

No

If yes, who?

Does child greet you when sees you?

Yes

No

If yes, how?

Does child attempt to involve you in activities?

Activity initiated by child or adult?

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Physical Stereotypy (Hand Flapping, Rocking, Pacing)

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Describe the behavior

What do you think causes it?

What do you do when it occurs?

How often per week?

Verbal Stereotypy (Repetitive Words/Phrases)

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Describe the behavior

What do you think causes it?

What do you do when it occurs?

How often per week?

Visual Stereotypy (Looking Corner of Eyes, Watching Spinning Items)

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Describe the behavior

What do you think causes it?

What do you do when it occurs?

How often per week?

FUNCTIONAL, SELF HELP, GROSS MOTOR, FINE MOTOR & SENSORY SKILLS

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Current Skill Level Assessment

Please indicate YES or NO and write detailed comments

Skill	Yes/No	Comments
Requires more help than children their age
Trips or falls frequently
Frequently drops things
Becomes frustrated easily
Is self-confident
Cries easily
Is able to move between activities without distress
Family changes routine to fit with child's behavior
Is able to participate in family social events
Plays in a repetitive manner
Shows awareness of own safety
Requires prompting to complete daily routine activities
Sleeps 8 hours per night
Knows own body parts
Is able to blow own nose
Can blow a whistle
Can drink from a straw

Self-Help Skills (Eating, Dressing, Toileting)

Skill	Yes/No	Comments
Feeds self with fingers
Feeds self with fork/spoon
Drinks from open cup without spilling
Put on shoes and socks
Put on shirt and pants
Take off shoes and socks
Take off shirt and pants
Use toilet when taken
Ask for toilet when needed
Does not have urinary accidents
Does not have bowel movement accidents
Can pull pants up and down for toileting
Washes hands
Brushes teeth
Combs hair
Washes face

Gross Motor Skills (Running, Jumping, etc.)

Skill	Yes/No	Comments
Stands on one leg momentarily
Jumps with feet together
Hops
Walks backwards
Walks sideways
Throw and catches a ball
Kicks stationary ball
Walks up/down stairs without assistance
Runs with smooth motion
Rides a bike

Fine Motor Skills

Skill	Yes/No	Comments
Hold pencil with fingertip grasp
Cuts paper with scissors
Can do up/undo buttons on self
Imitates hand gestures (e.g., pointing)
Opens bottles/jars
Picks up small object from flat surface

Sensory Skills (Sight, Sound, Smell, Taste, Balance)

Skill	Yes/No	Comments
Becomes car sick
Tolerates hair washing
Tolerates hair cutting
Tolerates nail cutting
Eats a variety of food textures
Is clumsy
Maintains attention to tasks
Is always "on the go"
Is easily distracted
Becomes irritated by particular sounds
Has irregular sleep pattern
Becomes overly emotional without clear cause
Is fearful frequently

Functional Status Summary

Brief description of what your child can do independently and tasks with difficulties

Gross Motor

Fine Motor

Self Care

Social/Emotional

Attention/Concentration

SPEECH & LANGUAGE - PLAY & COMMUNICATION

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Play & Communication Assessment

Skill	Yes/No	Comments
Attached to parent/sibling(s)
Plays with other children
Asks other children to play
Play with toys in their intended manner
Responds to their name
Will imitate others (clap hands, say "baa")
Can greet you verbally or gestural (wave hand)
Shows interest in other people
Retrieves/points to common objects upon request
Points to pictures when asked about
Does he/she say what he/she wants
Talks too fast
Stutters or getting "stuck" while talking
Repeats sounds, words, or phrases over and over
Uses pictures to communicate/request
Uses gestures or sign language to communicate
Uses single words to communicate
Uses sentences or 3-word phrases to communicate
Responds correctly to yes/no questions
Responds correctly to WH-questions (what, when, where, who, why)

SPEECH & LANGUAGE - SCHOOL ADDENDUM

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ℹ️ Complete if child is enrolled at school. Rate how often each behavior happens: Never (1), Sometimes (2), Often (3), Always (4)

LISTENING

Skill	Frequency (1-4)	Comments
Has trouble paying attention
Has trouble following directions
Has trouble remembering things people say
Has trouble understanding what people are saying
Has trouble asking questions

SPEAKING

Skill	Frequency (1-4)	Comments
Has trouble answering questions people ask
Has trouble using a variety of vocabulary words when talking
Has trouble thinking of (finding) the right word to say
Has trouble expressing thoughts
Has trouble describing things for people
Has trouble staying on the subject when talking
Has trouble putting events in the right order when telling stories
Uses poor grammar when talking

READING

Skill	Frequency (1-4)	Comments
Has problem sounding out words when reading
Has trouble understanding what was read
Has trouble identifying the main idea
Has trouble following written directions

WRITING

Skill	Frequency (1-4)	Comments
Has trouble writing down thoughts
Uses poor grammar when writing
Has trouble writing complete sentences

CR002 Questionnaire

CLIENT INFORMATION

FAMILY INFORMATION

PARENTAL CONCERNS

DEVELOPMENTAL HISTORY

DIAGNOSTIC INFORMATION

ASSESSMENT HISTORY

MEDICAL HISTORY & TESTING

CURRENT/PREVIOUS TREATMENTS & SERVICES

EDUCATION

RECEPTIVE LANGUAGE

EXPRESSIVE LANGUAGE - VOCAL COMMUNICATION

SOCIAL BEHAVIOR

MALADAPTIVE BEHAVIORS

Refusal/Failure to Follow Instructions (Non-Compliance)

Crying, Screaming, Dropping to Ground (Tantrum Behavior)

Hitting, Kicking, Scratching, Biting (Aggression)

Self-Injurious Behavior (Hitting/Scratching Self)

Difficulty Transitioning/Adjusting to New Routines

REPETITIVE PHYSICAL, VERBAL, VISUAL BEHAVIORS

Physical Stereotypy (Hand Flapping, Rocking, Pacing)

Verbal Stereotypy (Repetitive Words/Phrases)

Visual Stereotypy (Looking Corner of Eyes, Watching Spinning Items)

FUNCTIONAL, SELF HELP, GROSS MOTOR, FINE MOTOR & SENSORY SKILLS

SPEECH & LANGUAGE - PLAY & COMMUNICATION

SPEECH & LANGUAGE - SCHOOL ADDENDUM