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Child Development Questionnaire 2017 v2

This document contains a child development questionnaire for parents to complete. It collects information about the child's medical history, pregnancy/birth, developmental milestones, motor skills, personality, family relationships, daily routines, and any concerns regarding sensory processing or learning difficulties. The goal is to learn more about the child's current developmental abilities to assist in an evaluation. Parents are asked to describe their child's skills and behaviors in detail.

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Cnellia Vartolomei
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165 views

Child Development Questionnaire 2017 v2

This document contains a child development questionnaire for parents to complete. It collects information about the child's medical history, pregnancy/birth, developmental milestones, motor skills, personality, family relationships, daily routines, and any concerns regarding sensory processing or learning difficulties. The goal is to learn more about the child's current developmental abilities to assist in an evaluation. Parents are asked to describe their child's skills and behaviors in detail.

Uploaded by

Cnellia Vartolomei
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CHILD DEVELOPMENT QUESTIONNAIRE

Today’s date: First Step Diagnostician:


CHILD DETAILS:
First name: Last name: Birth date: Age: Corrected age
(preemies):

Gender:  M F Birth weight: Birth week:

Address: Home phone:

MOTHER'S DETAILS
First name:
last name: Occupation:
Age: Cell Phone:
Email:
Skype name:
FATHER’S DETAILS
First name: last name: Occupation:

Age: Cell Phone:


Email:
Skype name:
SIBLINGS:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
The Parents country of origin:
What is the language spoken between the parents:
What is the language spoken with the child:
What is the reason for contact with “First Step”?

Referred to “First Step” by:


Please state the medical diagnosis of the child's developmental difficulty:

Please describe the functional difficulties:

Association support  Yes  No , if yes which :

In which structure is the child? (home, kindergarten, school etc)

Information on child development from pregnancy to age 2 years:

Pregnancy: normal  Yes  No – Explain:

Labor:  Normal  C-section  Vacuum  Tongs


Apgar score post labor:
State of fetus in labor:  Breech  Normal  Width

Illnesses and hospitalizations:


Has the child been ill?  Yes  No – Explain:

Has the child been hospitalized? At age: Reason:


 No  Yes
Has the child undergone other treatments?  yes  no – Explain:
Treatment: Name of provider: Name of provider:

Treatment: Name of provider: Name of provider:

Has the child been diagnosed by another professional?  Yes  No:


* In the case of a treatment, please attach relevant documents.

Developmental background up to the age of 2:


Did the toddler progress through all the stages of motor development? (Lying on the stomach, lifted
the head, rolled, belly crawled, rose on hands and knees, sat down and stood up independently)

Was the child’s motor development slow, normal or quick?

Were there any developmental interventions during the first two years (physical therapy, speech
therapy, occupational therapy, orthopedist etc?)
*In the event that there were please attach all related materials.

Additional activities or classes:  Yes  No:

How would you describe the child as a baby: quiet, restless, nervous, cried frequently, rarely cried?

At what age did the child begin preschool or nursery school?

Describe the child’s sleeping habits as a baby: in arms, in the car, required a pacifier or other object
woke up often.
Were there special difficulties?

Developmental Background as child:


Does the child exhibit gross-motor skills? (Jumping, skipping, standing on one foot, rolling, running,
walking, other…)

Is there difficulty with fine-motor skills? (Eating, cutting, drawing, writing, threading, other…)

How would you assess the child’s general state of health?

Describe the child’s character and the special attributes of his personality.

Describe the family relations between the siblings and parents.

Is it easy for the child to create social contacts? Does he like being with friends?

What are your child’s preferred games?


Is there sensory sensitivity to touch or different textures? (Types
of foods, sand, grass, avoids dirt, other…)

Is there sensitivity to levels and intensity of sound?

Are there movement issues? (Falls a lot, avoids swinging, likes high intensity movement, other…)

Are there learning difficulties?

Have you encountered emotional difficulties? (Temper tantrums, low self-esteem, difficulty in expressing
emotions, cries a lot, overly irritated other…)

Please describe the child’s daily schedule by periods:


* Wakeup / how the child is roused
* Morning routine details
* Television
* Homework
* Friends
* Independent playtime
* Time with parents
* Meal details including snacks
* Bedtime routine details
* Falling asleep process
In order to help us learn more about your child’s current motor skill activity and levels, please answer
the following questions.
If you do not know the answers, encourage your child to move into these different positions and
observe the behavior and response:

Does the child lie on the stomach?  Yes  No


In what position does the child sleep?  On stomach  back  side  other

Does the child turn over to stomach from lying on the back?  Yes  No

Does the child move independently from lying on the back to sitting?  Yes  No
How? Through  the side  front  with help  other

Does the child sit independently?  Yes  No Does


he need help sitting down?

From lying on the stomach does the child stand on six?

Does the child crawl?  Yes  No

Does the child go from sitting on the floor to standing up independently?  Yes  No

Does the child go from sitting on a chair to standing up independently?  Yes  No

Does the child need to hold on to something when standing?  Yes  No

Does the child walk independently or does he/she need to hold on to something?  Yes  No

Is there a tendency to fall down when walking?  Yes  No


Can the child sit down from standing?  Yes  No

Additional information that you would like to share with us:

Thank you.

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