WELCH-SCHMIDT CENTER FOR COMMUNICATION ... · Web viewWelch-Schmidt Center for Communication Disorders MARTIN 34 Warrensburg, MO 64093 660-543-4272 (Office) 660-543-4167 (Fax) Author

PARENT QUESTIONNAIRE

Date: / /_______ Who referred for this evaluation and relationship to client: _________________________________________________________

IDENTIFICATIONChild's Name ________________________________________________________________

(first) (middle) (last)

Date of birth _______/________/__________ Sex __________mo day yr M / F

Address_________________________________________________________

City/State/Zip ____________________________________________________

Mobile Phone (______)______-__________

Home Phone (______)______-__________

Describe your child’s problem (s):

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

PREGNANCY AND BIRTH HISTORY

Did mother receive prenatal care? ______

Did mother take any medications, drugs, or consume alcohol during pregnancy? If so, please describe. ________________________________________________________________________________________

Mother's health during pregnancy: good___ fair___ poor___ Explain___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Page 1 of 17 Last Revised: 4/16/09

MIDWEST CENTER FOR AUTISM SPECTRUM DISORDERSWelch-Schmidt Center for Communication Disorders

MARTIN 34Warrensburg, MO 64093

660-543-4272 (Office) 660-543-4167 (Fax)

Baby's birth weight_________ Child’s birth was: normal _____ premature_____ overdue_____

Normal delivery? __________ If no, describe any special procedures or problems: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Condition of child at birth ____________________ APGAR, if known_____________________

Medical diagnosis at birth?

DEVELOPMENTAL HISTORY

Age the child did the following: sat alone____________ crawled alone _________ bowel control_______

walked alone___________ fed self_____________ tied shoes____ ____ rode tricycle_________ bladder control______ _ dressed self_________

Did your child sit up, crawl, stand up, and walk---in that order?

Does your child have any unusual toileting behaviors?

Describe any feeding problems (birth to present).

Did your child experience gastrointestinal problems?

Did your child display typical parent/child interaction as a baby?

eye gaze yes no cooing/vocal play yes no babbling yes no attending to your voice yes no imitate facial expression yes no

At what age did your child say his/her first words? ______ (please provide examples) ____________________________________________________________________________________


Did your child’s vocabulary develop “quickly” or “slowly and effortful”? Describe:

Did your child use meaningful phrases (word combinations) by age two? yes no

Did your child have normal development up to a certain age and then stop?

Did your child change in development at some point?

Did your child develop a skill(s) and then stop?

Describe your child as a baby (ie., good/happy baby, cranky, colicky, slept a lot, wouldn’t sleep, easy to hold, stiff, etc)

What difficulties has your child had since birth or soon after?

MEDICAL HISTORY

Describe any serious illness, injury, or surgery including hospitalizations (dates/age included)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has the child had (give ages): earaches____ ear infections____ hearing problems________ vision

problems____ frequent colds____ measles____ mumps____ meningitis_______ encephalitis______

asthma_____ head injuries_____tonsillitis____ allergies____ draining ears____ high fevers______

convulsions or seizures ____

Have any of these diseases resulted in past or present problems? If yes,

explain:___________________________________________________________________________________


__________________________________________________________________________________________

__________________________________________________________________________________________

Family physician_____________________________________________ Address____________________________________________________

Other physicians/specialists ___________________________________________________________________________ (Name) (Address)

___________________________________________________________________________ (Name) (Address)

___________________________________________________________________________ (Name) (Address)

Have you ever been concerned about your child’s behavior or speech/language and taken him/her to a specialist?

Has the doctor ever told you that your child has a behavior or language problem?

Has a doctor ever told you your child exhibits characteristics of a child with autism?

What services or programming has your child received?

Does your child take any medication?

Type Dosage/How often How long on med Type Dosage/How often How long on med Type Dosage/How often How long on med

HEARING HISTORYDo you think the child hears well?______ If not, why?_______________________________________________________________________________

Has the child received medical treatment for ear or hearing problems?______ If so, when?________________________________________________________________________________

Dr.'s name/address : ______________________________________________________________________________


Findings and treatment:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the child respond to: (please mark Y or N as appropriate)

his/her name__________verbal commands________loud noises_____gestures only_____seems to ignore sounds_______.

COMMUNICATION SKILLS: SPEECH / LANGUAGE / SOCIAL SKILLS DEVELOPMENT

At what age did the child first say words?________

At what age did the child combine two words ("want drink," "me go")? ___________

At what age did the child speak in simple sentences (three words or more)?___________

Did speech/language learning seem to stop for a time?________If yes, explain: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What languages are spoken in the home?________________________________________________________________________

How do you help your child communicate better?___________________________________________________________

Do you think your child was slow in learning to talk?_______ When did you first notice the speech/language problem?____________________________________________________________________________________________________________________________________________________________________________________

Was the speech/language problem noticed following an illness, accident or unusual occurence?____ If yes, explain:____________________________________________________________________________________________________________________________________________________________________________________

What does your child do if others have difficulty understanding him/her? __________________________________________________________________________________________


Does your child use gestures to communicate?_____ Has the child had any speech/language therapy? ___________When?_____________Where?__________________________________________________For how long?_____________________________________

Is the child aware of his/her speech/language problem? ____________________________________________________________

For the following questions, please provide as much description/examples as possible.

1. Provide some examples of your child’s first vocabulary.

2. Provide some examples of the phrase speech (2 words) used by your child.

3. When did your child start talking in sentences and having conversation?

4. Do you notice a different inflection, volume, pitch, or prosody?

5. Can others understand your child?

5. Do you notice jargon or vocalizations?

7. Does your child lack communicative intent?

8. Do you notice that your child repeats words, phrases or sentence?

9. Does your child exhibit repetitive speech?

10. Does your child have difficulty with pronoun usage?


11. Does your child use yes/no appropriately?

12. Does your child switch to a topic of interest when talking to others?

13. Does your child understand cause/effect?

14. Does your child understand concrete language versus abstract?

15. Does your child exhibit imitation skills?

16. Does your child initiate /maintain interactions/conversations?

17. Does your child demonstrate generalization of skills across environments?

18. Does your child demonstrate the ability to imitate?

19. Is your child a concrete vs. abstract learner?

20. Describe your child’s memory?

21. Does your child repeat words, phrases, sentences? If so, does he/she do it:Immediately Delayed Unrelated


22. How does your child:Request help

Request an object

Request an action

Protest or escape

Request a social routine

Request comfort

Indicate illness

Show you something

CAPACTITY TO RELATE TO PEOPLE, OBJECTS, EVENTS1. How does your child respond to affection?

2. Does your child demonstrate affection?

3. Does your child allow others to touch him/her?

4. Does your child invade others space?

5. How does your child interact with peers?

6. How does your child interact with siblings?

7. How does your child interact with adults?

8. Does your child prefer to be alone?


9. If your child was left to do what he/she wanted, what would he/she choose?

10. Does your child play with toys?

11. Does your child display a fascination with certain objects, machinery, computers, etc?

12. Can your child be left with others?

13. How does your child respond to change?

14. Does your child have tantrums?

15. How long are the tantrums?

16. How often are the tantrums?

17. What intensity are the tantrums?

18. Does your child seem to notice other people and/or different places?

19. Does your child like to be independent?

20. How does your child get what he/she wants?

21. How does your child respond to changes in routines?


22. How does your child respond to others’ facial expression?

23. Does your child exhibit appropriate facial expression?

24. What is your child’s response to joint attention?

25. Does your child laugh/cry for no apparent reason?

26. Does your child display fears?

27. Does your child appear to understand nonverbal communication?

28. Does your child have any type of repetitive behaviors?

29. How are your child’s organizational skills?

30. How does your child respond to humor or teasing?

31. Does your child play with toys appropriately?

32. How does your child do with transportation?

33. Is it difficult to take your child out in public?

34. When in public how does your child react to new people?


SENSORY AND BEHAVIORS EXHIBITED1. Does your child exhibit any of the following behaviors?

Biting nails_____Twitching______Hand movements______Arm movements______Finger movements______Twirling self/objects______Biting self/others______Hitting self/others______Pinching self/others______Head banging______Fascination with spinning objects______

2. How does your child respond to the following:

Visual: Do you ever notice your child staring?

Does your child make eye contact in the usual way?

Is your child distracted with visual activity?

Does your child have a reaction to bright light?

How long is your child able to pay attention?

Auditory: Does your child respond to his/her name?

Is your child hyper/hypo responsive to sounds?

Is your child distracted by auditory activity?

Tactile: Does your child touch or rub items?

Does your child mind being messy?

Does your child avoid/seek physical contact?


How does your child respond to his/her clothing?

Proprioceptive/Vestibular/Modulation and Regulation: Has rocking/flapping/twirling been observed?

What is your child’s activity level?

Does your child have gravitational issues?

Has your child ever toe walked?

Have you noticed tics/grimaces?

Olfactory/Gustatory: Does your child put non-edibles in his/her mouth?

Does your child smell or sniff items, food, or people?

How does your child react to pain/temperature?

Does your child demonstrate distress during grooming?

Does your child demonstrate distress when going to the doctor?

Does your child have a strong food preference?

Does your child gag easily?

Does your child exhibit distress during grooming?

Does your child exhibit distress during dental work?


Does your child exhibit distress during doctor’s appointments?

3. Does your child have any other unusual reactions?

4. Is your child fearful or frightened some of the time for no apparent reason?

5. How does your child respond to dangerous situations?

6. Does your child sleep through the night?

ADAPTIVE SKILLS1. Can your child your child put on/take off:

Put on Take offShirt _____ ______Pants _____ ______Shoes _____ ______Socks _____ ______Underwear _____ ______Coat _____ ______

2. Can your child complete the following fasteners:Start a zipper______Zip______Button______Unbutton______Snap______Tie shoes______

3. Can your child:Use a spoon______Use a fork______Use a knife______Drink from a cup______Pour with little spilling______

4. Can your child:Toilet independently______Wash hands______

5. Does your child take a shower/bath?6. Does your child wash independently?7. Does your child wash hair independently?8. Does your child like or dislike the bathing process?9. Does your child brush their teeth independently?


10. Does your child mind toothpaste?

SOCIAL HISTORY

Child's interests, hobbies, play activities?

Child's playmates (age):

What are the attitudes of the other children towards your child?

EDUCATIONAL HISTORY

Present school____________________________________________________________________________ Address_________________________________________________________________________________

Teacher___________________________ Grade______ School performance: Superior____ Average____ Poor____

Describe any problems the child is having in school:

List the schools previously attended and years.

How does the student do academically (grades/ test scores)?

How does the student get along with peers?

How does the student get along with teachers and other authority figures?

What is the student’s favorite/easiest/best subject?


What is the student’s least favorite/ most difficult / worst subject?

Does the student participate in extracurricular activities? If so, which?

Does the student’s behavior interfere with his/her learning, or that of classmates?

Describe the student’s school disciplinary history.

Any other concerns related to school?

Family, Home and HealthWho else lives in the home?

Any recent changes or losses in family status? If so, please describe.

Who in the family is the child closest to?

Does the child have any significant conflicts with any family members?

Does the child do anything at home that concerns you?

How do you manage the child’s behavior problems at home?

Describe the student’s typical routine on a school day.


What does the student like to do in his/her spare time?

Describe the student’s hobbies or special interests.

Describe the student’s responsibilities around the house.

How would you describe the student’s health during the developmental years?

Has the student ever been hospitalized?

Does the student have any current health problems?

Does the student take any medications?

Any other concerns related to family, home or health?

Are there any other family members with Autism?

DISCIPLINE

What form of discipline do you use in your home?What have you found to be most effective?

How does your child respond to correction?

Who administers discipline?


RELATED SERVICES

If the child has received services from a psychologist, a neurologist, speech-language pathologist, or other "specialist," please give name, address, and date seen. Also, please have them send a copy of their findings to our clinic:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTHER

Name of person completing this form _____________________________

Relationship to child ________________________________

What do you want for your child educationally?

What do you want for your child’s future?

Is there anything else we need to know about your child?

Signature __________________________________________________________

To whom would you like reports sent?

1. Name_______________________________________________________________________________

Address_____________________________________________________________________________

2. Name_______________________________________________________________________________Address_____________________________________________________________________________

*Adapted from questionaire developed by Suzette Southwick


Documents

WELCH-SCHMIDT CENTER FOR COMMUNICATION ... · Web viewWelch-Schmidt Center for Communication Disorders MARTIN 34 Warrensburg, MO 64093 660-543-4272 (Office) 660-543-4167 (Fax) Author