Preschool Questionnaire Fill out the Preschool Questionnaire PRE-SCHOOL QUESTIONNAIRE To be completed by child’s preschool teacher or daycare providerDate: MM slash DD slash YYYY Child's First Name: Child's Last Name: Age: Hand dominance:RightLeftUnclearTeacher(s)'s Name(s): School: Email: Phone Number:Best time to call: Address: # of students in class Age range: Days/times child attends: Classroom Concerns (include behaviors or skills that are different than those of peers):Child's strengths/ preferred activities:List any activities that child avoids:Please list any support services this child is receiving:List any classroom modifications or support being provided (if any):POSTURAL AND GROSS MOTOR:Please complete the following observation checklist:Unusual walking or running pattern (dragging feet, stiff, on toes, falls often) Seldom Sometimes Often Not Observed Poor posture, slouches Seldom Sometimes Often Not Observed Tires easily, poor endurance Seldom Sometimes Often Not Observed Awkward gross motor skills (hopping, climbing, skipping) Seldom Sometimes Often Not Observed Fearful of heights Seldom Sometimes Often Not Observed Awkward/hesitant on stairs Seldom Sometimes Often Not Observed Poor balance Seldom Sometimes Often Not Observed Bumps into chairs, walls, etc. Seldom Sometimes Often Not Observed BASIC SENSORY FUNCTIONING:Pushes, shoves, hits or kicks when near other children Seldom Sometimes Often Not Observed Dislikes being touched unexpectedly Seldom Sometimes Often Not Observed Avoids messy play/art Seldom Sometimes Often Not Observed Easily overwhelmed by too much noise, movement Seldom Sometimes Often Not Observed Bothered by loud noises Seldom Sometimes Often Not Observed Bothered by bright light, sun, etc. Seldom Sometimes Often Not Observed Craves spinning, fast movements; does not get dizzy Seldom Sometimes Often Not Observed Seeks out sensory input – touching, pushing, crashing Seldom Sometimes Often Not Observed Tends to invade other’s personal space Seldom Sometimes Often Not Observed FINE MOTOR:Difficulty manipulating small objects (i.e. pegs, beads) Seldom Sometimes Often Not Observed Difficulty handling clothing fasteners Seldom Sometimes Often Not Observed Shaky or jerky hand movements Seldom Sometimes Often Not Observed Atypical grip with pencil, crayons or markers Seldom Sometimes Often Not Observed Lacks good control with crayons, pencils, or scissors Seldom Sometimes Often Not Observed Difficulty cutting with scissors Seldom Sometimes Often Not Observed VISUAL PERCEPTION:Difficulty putting together puzzles Seldom Sometimes Often Not Observed Limited drawing/ pictures not recognizable Seldom Sometimes Often Not Observed Difficulty reproducing simple shapes Seldom Sometimes Often Not Observed LEARNING BEHAVIOR:Unable to attend to task as long as classmates Seldom Sometimes Often Not Observed Easily distracted Seldom Sometimes Often Not Observed Wiggles a lot; can't sit still Seldom Sometimes Often Not Observed Disorganized, messy Seldom Sometimes Often Not Observed Slow worker Seldom Sometimes Often Not Observed Appears to have difficulty comprehending what is going on around him/her Seldom Sometimes Often Not Observed SOCIAL-EMOTIONAL:Behavior annoys or bothers others Seldom Sometimes Often Not Observed Impulsive Seldom Sometimes Often Not Observed Lacks confidence ( says " I can't or "too hard" ) Seldom Sometimes Often Not Observed Easily frustrated Seldom Sometimes Often Not Observed Short attention span Seldom Sometimes Often Not Observed Overly active/difficulty sitting still Seldom Sometimes Often Not Observed SPEECH AND LANGUAGE SKILLS:Difficulty following directions Seldom Sometimes Often Not Observed Difficulty understanding what people are saying Seldom Sometimes Often Not Observed Difficulty looking at people when talking or listening Seldom Sometimes Often Not Observed Difficulty understanding facial expressions, gestures, or body language Seldom Sometimes Often Not Observed Difficulty answering questions Seldom Sometimes Often Not Observed Difficulty asking questions Seldom Sometimes Often Not Observed Difficulty expressing thoughts Seldom Sometimes Often Not Observed Speech is difficult to understand Seldom Sometimes Often Not Observed Difficulty carrying on a conversation Seldom Sometimes Often Not Observed PLAY SKILLSLimited imaginary or pretend play Seldom Sometimes Often Not Observed Tends to play alone most of the time Seldom Sometimes Often Not Observed Difficulty making friends Seldom Sometimes Often Not Observed Has difficulty organizing own play Seldom Sometimes Often Not Observed Limited construction/building play Seldom Sometimes Often Not Observed Comments:
