PARENT QUESTIONNAIRE FOR THE PRE-SCHOOL CHILD by luckboy

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									PARENT QUESTIONNAIRE FOR THE PRE-SCHOOL CHILD
Please complete the following questionnaire giving as much information as you can. Tick or circle all responses where appropriate and use a separate sheet if required. Family Details Child’s Name: Parents’ Names: Home Address: Date of Birth: Child’s Age: Home Tel. Number: Work Tel. No/Mobile: Mother: Father: Post Code: Brothers/sisters and ages: Fax No: E-mail: List of people living at home:

Is your child adopted? If so, at what age? General Practitioner’s Name: Address:

Yes/No

Is your child aware of this?

Yes/No

Post Code:

Telephone No:

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926

Concerns and Expectations Briefly list the main concerns about your child:

Pregnancy/Birth History Did you experience……. An uneventful (normal) pregnancy? Difficulties during pregnancy? If so, what? Excessive sickness during pregnancy? Did this continue throughout the pregnancy? Describe if appropriate

Was your labour…….? Normal Forceps, Ventouse Caesarean Section Premature Late Any post-natal problems? Post-natal depression Were there any difficulties in the first month after birth?

If so, by how much? If so, by how much?

If so, what?

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926

Developmental History (please refer to your ‘parent-held record book’ (Baby Book)) At what age did your child: Sit unsupported? Crawl? (If not, did s/he ‘bottom hotch’ or ‘commando crawl' ? Walk? Talk? By day: By night: Any current problems? YES/NO

At what age was your child toilet trained?

Did your child have any feeding difficulties? If so, please describe.

Was your child: Did/does your child: Suck a dummy? Is your child: Medical History

Breast fed? Bottle fed? Suck his/her thumb? Right/Left-handed? Still demand a bottle?

Does your child have/has your child had…? A serious illness A serious injury Surgery Any allergies Convulsions/fits History of glue ear History of head injury

If so, please describe and give dates

Current medication (Please name medication and reason for prescription) Any other treatments please state:

Hearing test Sight test

Date: Date: YES/NO

Outcome: Outcome: If so, what for?

Does your child wear glasses?

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926

Has your child had an assessment with an …? Outcome: Occupational Therapist Date: Physiotherapist Date: Educational Psychologist Date: Clinical Psychologist Date: Dietician Date: Other (please state) Date: Portage/Home Advisor Service Date: Health Visitor Date: Paediatrician Date: Speech and Language Therapist Date: Outcome:

Pre-School History Name of day-care facility: Contact name: Address: Telephone: Fax: E-mail:

Post code: Day-care Full-time/part-time Nanny Nursery/crèche Childminder Playgroup Home with parent Frequency

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926

Social and Emotional Development Which would you say describes your child? (tick as applicable) Quiet Overactive Upset by failure Impulsive/no fear of danger Does your child…..? Have a good relationship with his/her siblings? Relate to other children? Play with children: Older? Younger? Have any unusual fears? If yes, please describe. Same age? Withdrawn Anxious Shy Behavioural problems at home Emotional Aggressive Temper tantrums Behavioural problems at day-care facility

Have favourite: If so, what?

Toys Family outings Interests

Belong to any pre-school groups? If so, what?

Listening and Communication Skills Does your child..? (tick as applicable) Seem oversensitive to sound? Misinterpret simple questions/instructions? Get confused by similar sounding words? Use gesturing only to make themselves understood? Have difficulty with speech sounds? Appear to listen but not understand? Have hesitant speech? Understand other’s gestures and facial expressions? Use gestures to refine verbalisation?

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926

Sensory Motor Behaviour Does your child..? (tick as applicable) Get car sickness easily? Tire excessively? Appear to be excessively accidentprone? Crave spinning or swinging? Appear fearful of playground apparatus/soft play areas? Dislike hugs and cuddles? Have extreme dislike of baths or hair washing? Get irritated by certain textures? Dislike certain food textures? Have an excessive need to touch or taste things?

Visual Skills Have you noticed your child….? (tick as applicable) Having red eyes? With one eye turning in or out? Closing/covering one eye? Turning or tilting their head? Blinking or squinting? Sit very close to the television? Does your child….? (tick as applicable) Enjoy jigsaw puzzles? Sit and look at pictures in a book? Make an attempt to colour within lines?

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926

Self-help Skills Dressing/undressing (tick as applicable) Able to undress (but may need help with fastenings) Able to put on large garments (but may need help with fastenings) Able to put on socks Can put shoes on correct feet with verbal prompting (does not fasten) Personal hygiene…. Indicates when needing to empty: bladder bowels Can use toilet/potty with minimum help: bladder bowels (not wipe bottom) Attempts to adjust clothes after toileting Washes and dries hands independently: with verbal help with physical help Eating and drinking…. Lifts a cup and drinks from it using: both hands one hand Eats using: fingers spoon fork and spoon knife and fork chopsticks other…………………..………. Attempts to brush hair Attempts to clean teeth Can wipe own nose Allows adult to wipe nose Gets on/off toilet: with help without help Fastenings….. Can pull up zip Can undo/do up large buttons Can fasten poppers

Gets in/out of bath: with help without help Sleeping…. Goes to bed and sleeps easily Sleeps through the night If not, describe waking pattern: Likes sleep routine e.g. bath, story, bed Can get on/off the bed: with help without help

Can get in/out of car:

with help without help

*Does your child sleep in any place other than their own bed? If YES, please describe:

* only complete if aged 3 and above

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926 !

Balance and Co-ordination Outdoor…. Insistent on holding adult hand when walking Happy to walk without help Confident on uneven surfaces Manages steps and kerbs: with ease with difficulty needs help Is able to walk continuously on a level surface for 10 minutes Is able to ride a tricycle: with pedals without pedals Indoor…. *Walks up stairs: *Walks down stairs: 2 feet to 1 step 1 foot to 1 step 2 feet to 1 step 1 foot to 1 step

*Jumps off one step both feet together *Can walk on tiptoes *Can hop briefly on one foot *Can balance briefly on one leg *Climbs on and off furniture without help Is able to carry an object while walking Squats down to pick up objects

*only complete if aged 3 and above

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926 "

Play Does your child usually…… Play alone Play alongside other children Play with other children Require adult support Engage in pretend play Does your child like to scribble or colour Does your child avoid any play activity at home or at their day-care facility? YES/NO If YES, please describe Ball skills – can your child……. Stand on one leg and kick a ball without losing balance Hold their hands out to catch a ball Roll a ball to another Does your child prefer to play…… Lying on their tummy Sitting on the floor Sitting between their heels Standing at a low table/sofa

Thank you for completing the questionnaire. Please return it with any other reports/supporting information and the Nursery/Playgroup Questionnaire to: Sharon Drew MA (SEN) DipCOT ‘Brierfield’ 37 Mill Street Usk Monmouthshire NP15 1AP

37 Mill Street, Usk, Monmouthshire, NP15 1AP E-mail: enquiries@smartcc.co.uk Web: www.smartcc.co.uk Phone/Fax: 01291 673926


								
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