Parent Questionnaire | Emerge Pediatric Therapy

Fill Out the Caregiver Questionnaire

Caregiver Questionnaire

Date
Date Format: MM slash DD slash YYYY
Child's First Name*
Child's Last Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Sex
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Who referred child to Emerge:
Phone Number*
Address
Reason for Referral:
FAMILY INFORMATION:
Parent's Name
Birthdate*
Date Format: MM slash DD slash YYYY
Occupation
Cell Phone
Place of Employment
Business Phone
Email Address*
Parent's Name
Birthdate*
Date Format: MM slash DD slash YYYY
Occupation
Cell Phone
Place of Employment
Business Phone
Email Address
With whom does child live?
Biological Parent(s)
Adoptive Parents
Adopted at Age:
Other (Specify)
Health Insurance company
List all other persons living in home:
Name / Age / Relationship to child
BIRTH INFORMATION:
Any difficulties during pregnancy or delivery (Specify)
Length of Pregnancy
Length of Labor
Birth Weight
Any problems in newborn period (Specify)
SCHOOL HISTORY:
Please provide location and dates.
Preschool or daycare
Kindergarten
Elementary School
Present grade
School
Teacher
Phone
Is your child in a special class or receiving any support services?
Please list all
DEVELOPMENTAL MILESTONES:
Specify the age at which your child (leave blank if not applicable or you don’t remember):
Sat without support
Crept on hands & knees
Walked independently
Jumped
Rode a tricyle
Dressed independently
Named simple objects
Rode a bicycle
(no training wheels)
Used single words
(e.g., no, mom, dog)
Combined words
(e.g. me go, daddy)
Used simple questions
(e.g. Where's cup?)
Engaged in conversation
Drew a recognizable picture
Cut out a shape with scissors
Do or did you have any concerns about your child's achievement of early developmental milestones?
- Yes
- No
If yes, please describe:
PROFESSIONAL AND MEDICAL CONTACTS:
Please list any of the following with whom you have had contact concerning your child. If any of these professionals have tested your child, please include a copy of the report.
Pediatrician
Name/Address/Phone
Psychologist
Name/Address/Phone
Tutor
Name/Address/Phone
Occupational Therapist
Name/Address/Phone
Physical Therapist
Name/Address/Phone
Speech Therapist
Name/Address/Phone
Neurologist
Name/Address/Phone
Other (specify)
Name/Address/Phone
List any medications that your child is currently taking:
List any allergies your child has (including food):
Has your child had any surgeries? If yes, what type and when (e.g. tonsillectomy, tube placement, etc.)?
Has your child’s hearing been tested (when and results):
Has your child‘s vision been tested (when and results):
ACTIVITY HISTORY :
Please provide any past or current activities along with your child's reaction to the experience.
Gymnastics
Music Class/lessons
Dance or movement class
Karate or Tae Kwon Do
Scouting
Organized sports
Other
What does your child enjoy playing with? How does your child entertain him/herself?
What are your concerns about your child?
What have you been told by doctors, teachers and/or others about your child?
Please include any diagnoses you have been given.
What do you see as your child's strengths?
Please describe a typical day for your child, particularly if you have any behavioral concerns.
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Caregiver Questionnaire

Fill Out the Caregiver Questionnaire

Caregiver Questionnaire

FAMILY INFORMATION:

BIRTH INFORMATION:

SCHOOL HISTORY:

DEVELOPMENTAL MILESTONES:

PROFESSIONAL AND MEDICAL CONTACTS:

ACTIVITY HISTORY :