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Parent Questionnaire
Patient: DOB:
Address: Age:
Phone Number: Sex:
School: Grade:
Pediatrician:
Parent/Legal Guardian:
Emergency Phone #:
Medical Hx:
Was the child born full term?
Were there any complications during pregnancy? ____yes ____no
Please describe:
Were any medications prescribed during pregnancy?
Please list:
Delivery: ____vaginal ____C-Section
Any complications during delivery?___yes ____no
Please describe?
Does the child have any allergies:____yes ____no
Please list:
Please list any hospitalizations and/or surgeries:
Has the child been given a diagnosis? ____yes ____no
Please state diagnosis:
Onset:
Please list physician who diagnosed the child?
Developmental Hx:
When did the child sit independently?
When did the child crawl?
When did the child walk independently?
Does the child have any difficulty feeding?
Does the child have any difficulty with sensory integration?
Does the child independently manage activities of daily living?
When did the child speak first words?
When did the child use 2 word combinations?
When did the child begin using simple sentences?
If the child is nonverbal, how does he/she communicate?
Does the child use augmentative communication?
Has the child received PT, OT, or Speech services?___yes ____no
If yes, please list type and dates of service:
Family Hx:
Is there family history of developmental delays or other communication related disorders?
Does the child have siblings? ___yes____no
Please list ages of siblings:
Academic Hx:
How is the child progressing in school?
Does the child demonstrate behavior problems in school?
Is the child receiving special education services (IEP)? ____yes ____no
*What are your child’s strengths?
*What types of toys, games, or activities does your child enjoy?
*As a parent, what goals would you like to see your child accomplish?
Will person transporting child to and from services be someone other than parent or legal guardian? ____yes _____no
If yes, please state the following:
Name:
Phone #:
Relationship to child: _________________
Do you consent to release of information to this person with regard to the child’s progress in therapy and recommendations for carryover? ____yes ____no initial:___________
X________________________ ______________________________
Signature of Parent Printed Name
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