CENTER

PARENT QUESTIONNAIRE
Dear Parent,
Please fill out this form as best you can. Having all the facts will help us do the most thorough evaluation
and be most helpful to you. If you cant remember something exactly, put an approximate answer with a
question mark. Please feel free to use the backs of the pages for extended answers.
Childs Name: _______________________________________________ Birthdate: _________________________
Sex: _____________ Age: _________ Grade: _______ School: ______________________________________
Ethnicity: ___________________________________

Mothers name: ________________________________ Mothers Occupation: _____________________________

Fathers name: _________________________________Fathers Occupation:_______________________________
Home Address: _______________________________________________________________________________
Home telephone: _______________________Work telephone: ________________Cell:______________________
email: _________________________________________________________________________________________
Name of person completing form: __________________________________________________________________
Relation to child: ________________________________________________________________________________
Who else did you consult while completing this form?:________________________________________________
Relation to the child?: _______________________________________________________________________________
Who were you referred by?: _______________________________________________________________________________

Is your child adopted? ______________

Right or Left-handed?:_____________
If your child is left-handed are there other family members who are left-handed?:
_____________________________________________________________________________________________
Hair color: _____________ Eye color: _________________
Date of last vision test & results: ________________________________________________________________
Date of last hearing test & results: _______________________________________________________________
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1. What specific questions do you hope to have answered by this evaluation/consultation and/or treatment
(e.g., learning issues, giftedness, social, and/or emotional issues)?

2. Do you have any concerns about your child? (If No, skip to question 6 below)

3. What do you think may be causing the difficulties you are concerned about?

4. What interventions have you tried in the past to help with these areas of difficulty?
(e.g., tutoring, counseling, speech therapy, occupational therapy, behavior management programs, etc.)

5. What do you consider to be this childs greatest:

A. Strengths:

B. Challenges:

6. Has this child already had testing/evaluations/an IEP? If yes, what were the results and conclusions?
(Please include copies of reports and IEPs.)

7. What other information do you think is important for us to know about your child?

8. PRENATAL HISTORY:
How was your general health during the pregnancy? _________________________________________________
How was did you feel emotionally during your pregnancy? ________________________________________________
Any particular life stressors during the pregnancy? ______________________________________________________
How much weight did you gain during the pregnancy? ________lbs.
How active was the baby? ________________________________________________________________________
Check ( ) which of the following conditions occurred, if any, and then elaborate:
( ) Edema (swelling of feet) ______________________________________________________________________
( ) High blood pressure _________________________________________________________________________________
( ) Fever/Infections ____________________________________________________________________________________
( ) Vaginal bleeding ___________________________________________________________________________________
( ) Hospitalizations ____________________________________________________________________________________
( ) X-rays/medical procedures ___________________________________________________________________________
( ) Trauma accidents ___________________________________________________________________________________
( ) Exposure to environmental toxins (e.g., paint, chemicals) ___________________________________________________
( ) Other (anemia, poor health, seizures, etc.) ________________________________________________________________

List any medications (prescribed or over-the-counter) or injections you received during this pregnancy:
Medication

Reason

Amount Taken

During what months?

_______________

_______________

_________

______________________

_______________

_______________

_________

______________________

_______________

_______________

_________

______________________

_______________

_______________

_________

______________________

Check () any that apply and describe frequency & quantity used & during what months:
( ) Cigarettes _________________________________________________________________________________________
( ) Alcohol ___________________________________________________________________________________________

( ) Drugs (e.g., cocaine, speed, heroin, marijuana, LSD, etc.) _______________________________________________________

How was your nutrition during the pregnancy?________________________________________________________________

Did you get regular exercise? How often, how much? __________________________________________________________
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9. BIRTH HISTORY:
Birth weight: _____lbs. _____oz. Length: _________

Apgar Scores: ___________

Place of Birth: ____________________________________________ # of days baby in hospital: ____________

Type of birth: ( ) vaginal ( )c-section
Presentation: ( ) head
Type of anesthesia:
Was your baby:

( ) breech

( ) gas

( ) on time

( ) spinal
( ) early

( ) caudal block
( ) late By how many days/weeks: _____

Number of hours in labor: __________

Please check ( ) and EXPLAIN below:

Was there anything wrong with the baby before delivery? ( ) yes

( )no

If yes, describe: _______________________________________________________________________________

After delivery, was there any difficulty with:

( ) breathing

( ) cord around neck

( ) jaundice

( ) poor suck/feeding

( ) other: _____________________

Did the baby receive special treatments for any problems? ( ) yes

( ) no

If yes, please check and explain further:

( ) bilirubin lights __________________________________________________________________________________
( ) IVs (fluids, medicines, etc.) _______________________________________________________________________
( ) evaluation in an intensive care nursery _______________________________________________________________
( ) oxygen or respirator _____________________________________________________________________________
( ) special feedings _______________________________________________________________________________
( ) other ________________________________________________________________________________________

What was the birth like for you?__________________________________________________________________

What was the birth like for your partner? ___________________________________________________________
How did you feel during the first few days after the birth?_____________________________________________
How did your partner feel/respond during the first few days after the birth?______________________________
_____________________________________________________________________________________________
How were things in the home environment during the early weeks and days of the babys life?
_____________________________________________________________________________________________
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10.

DEVELOPMENTAL HISTORY:

Please check ( ) which milestones this child has achieved or can now do. Give the childs approximate
age in weeks or months when s/he first could do them. If the child is unable to do a particular activity
write N/A. If you cannot remember or do not know when the child was first able to do an activity write
D/K. You may find that a baby book, dated photos, and association with various events in your life may
help you remember these things.
( ) Roll from front to back and back to front ___________________________________
( ) Sit unsupported ________________________________________________________
( ) Creep or crawl on hands and knees _______________________________________
( ) Walk alone unsupported _________________________________________________
( ) Walk up stairs, alternating feet __________ Walk downstairs, alternating feet ______
( ) Pedal a tricycle ___________ ( ) Pedal a bicycle
( ) Reach out for a nearby object __________ ( ) Throw a ball ___________
( ) Feed self with fingers _________ ( ) Feed self with spoon _________
( ) Drink from a cup without help _______________
( ) Undress self ________ Dress self ________ Tie shoes ________
( ) Toilet trained _________________________________________________________
Describe your toilet training methods & how this period went: ____________________________________
_____________________________________________________________________________________________
( ) Babble with sound like baba/mama ______________________________________
( ) Point to specific objects ________ ( ) Point to body parts ____________________
( ) Understand no, or stop it _____________
( ) Say a word with meaning (not just mama/dada) ______________________________
( ) Follow a simple command __________________
( ) Put two or more words together in a simple phrase _____________________________________________
( ) Name a color correctly ____________________
( ) Speech is clear to both family members and strangers ___________________________________________
As a baby, was your child (circle as many as apply): intense, interested in her/his surroundings, friendly
with strangers, affectionate, attached to an object, overactive, independent, more interested in people,
more interested in objects, a self-starter, other:
How would you describe your childs personality?
As an infant?___________________________________________________________________________________
As a toddler? _________________________________________________________________________________
As a 3-5 year-old? _____________________________________________________________________________
As a 6 year-old?________________________________________________________________________________
7-8 year-old? _________________________________________________________________________________
8-10 years?___________________________________________________________________________________
10-12 years? _________________________________________________________________________________
12-14 years? ________________________________________________________________________________
14-18 years? ________________________________________________________________________________
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Any history of:

Age Began
Check if Still
Head banging_________________________________________________________________________________
Stuttering____________________________________________________________________________________
Breath holding________________________________________________________________________________
Day soiling___________________________________________________________________________________
Temper tantrums______________________________________________________________________________
Nail biting____________________________________________________________________________________
Excessive Jealousy____________________________________________________________________________
Hitting_______________________________________________________________________________________
Frequent crying_______________________________________________________________________________
Irritability_____________________________________________________________________________________
Excessive thumb sucking_______________________________________________________________________
Excessive masturbation________________________________________________________________________
Hurting self___________________________________________________________________________________
Sleep problems_______________________________________________________________________________
Nightmares___________________________________________________________________________________
Bedwetting___________________________________________________________________________________
Excessive fears_______________________________________________________________________________
Excessive fantasizing_ _________________________________________________________________________
Intentionally hurting others______________________________________________________________________
Problems going to school_______________________________________________________________________
Problems making friends_ ______________________________________________________________________
11. CHILD HEALTH HISTORY:
Please check all of the following which this child has had and explain as necessary in the open space
following each item:
( ) Hospitalizations____________________________________________________________________________
( ) Surgery__________________________________________________________________________________
( ) Trauma (lacerations, fractures, serious accidents, etc.)_ _________________________________________
( ) Head injury_ ______________________________________________________________________________
Loss of consciousness: ( ) yes ( ) no_________________________________________________________
( ) Seizures/convulsions/fits___________________________________________________________________
( ) Meningitis________________________________________________________________________________
( ) Other serious illnesses/infections/high fevers__________________________________________________
( ) Asthma/allergies_ _________________________________________________________________________
( ) Ear infections How many?_________
( ) Hearing problems__________________________________________________________________________
( ) Vision problems ___________________________________________________________________________
( ) Sleep problems (including nightmares, sleepwalking, bedwetting, etc.)_____________________________
( ) Toileting problems_ ________________________________________________________________________
( ) Temper tantrums/aggressive behavior_ _______________________________________________________
( ) Crying spells _ ____________________________________________________________________________
( ) Unusual behaviors (e.g., rocking, flapping, picking at self, etc.)____________________________________
( ) Other problems, describe:_ _________________________________________________________________
____________________________________________________________________________________________
( ) Medications (specify type and for treatment of what condition)___________________________________
____________________________________________________________________________________________
Do you have any concerns about this childs eating habits, diet, nutrition, or growth?
( ) yes ( ) no If yes please describe:________________________________________________________
____________________________________________________________________________________________
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12.

FAMILY HISTORY:

Please describe all pregnancies of this childs mother: List each time a pregnancy occurred and the type
(e.g., full term, premature, stillborn, miscarriage, etc.) Describe pertinent health issues of each child.
Year of birth:

Type:

Male/Female:

Health Issues

1.___________________________________________________________________________________________
2.___________________________________________________________________________________________
3.___________________________________________________________________________________________
4.___________________________________________________________________________________________
Information regarding biological parents:

Age now:

Health Issues:

If deceased, age/cause:

Mother:______________________________________________________________________________________
Father:_______________________________________________________________________________________

Please check all of the following which any immediate biological relatives of the child (e.g., father/
mother, grandparents, brother/sister, aunt/uncle, cousin) may have had, and explain as necessary in the
space next to each item:
( ) Inherited/genetic conditions__________________________________________________________________
( ) Birth defects_______________________________________________________________________________
( ) Cerebral palsy/neuromuscular disorders_ ______________________________________________________
( ) Slow or delayed development________________________________________________________________
( ) Learning disabilities/dyslexia_ ________________________________________________________________
( ) Hyperactivity/attention deficit disorder (ADD, ADHD)____________________________________________
( ) Hearing/visual problems_____________________________________________________________________
( ) Thyroid or other hormone disorder_ ___________________________________________________________
( ) Cancer____________________________________________________________________________________
( ) Alcoholism or drug abuse____________________________________________________________________
( ) Emotional problems/nervous breakdown_______________________________________________________
( ) Schizophrenia______________________________________________________________________________
( ) Manic Depression/Bipolar Illness_____________________________________________________________
( ) Depression________________________________________________________________________________
( ) Anxiety____________________________________________________________________________________
( ) Autism/ Aspergers_________________________________________________________________________
( ) Gifted_____________________________________________________________________________________
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13. SOCIAL HISTORY:

Please list who lives in the home with this child:

How long did the child sleep in the parents bedroom?

Does the child now or in the past share a room or bed with someone else? With whom? At what age?

Describe history of day care and list who currently cares for this child throughout the day:

Briefly describe school history. What schools has the child attended? Has the child repeated or skipped
any grades? In what academic areas has the child done well or done poorly? Describe involvement in extracurricular school activities, such as sports, clubs, etc.

Briefly describe the childs socialization history. How well does s/he relate to other children who are the
same age? Has this pattern changed over time? How well does s/he relate to adults and older children?
Does this child have many friends? A few friends? Very few friends? Does s/he frequently get into arguments or fights with peers?

Please describe guardians who primarily raised this child:

Name:

# of years in school:

Occupation:

Marital Status:

1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________

Please describe siblings:

Name:

Age:

School Grade:

1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________

How would you characterize your childs relationship(s) with his/her siblings?

What is your childs relationship like with you?

What discipline methods have you found to be most effective with your child?

What are your childs favorite activities?

What are your childs least favorite activities?

In what after-school activities does s/he participate?

Please list any chores or jobs your child has at home (e.g., paper route, babysitting, making her/his bed, etc):

How well does your child carry out the above chores?

Has your child ever been in counseling or therapy? Please describe any previous counselingreasons for
treatment, length of treatment, therapist name, type of treatment (e.g., family, individual, group therapy).

Any other relevant information about the family, such as information about divorce, remarriage, parental death,
death of other important family figures, etc.:

Is there anything else you wish to add that has not been covered by this questionnaire?

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