School Questionnaire Fill out the School Questionnaire SCHOOL QUESTIONNAIRE Date: MM slash DD slash YYYY Child’s First Name: Child’s Last Name: Age: Grade: Teacher(s)’s Name(s): School: Address: Email: Phone Number: Best time to call: Classroom Concerns:Child’s strengths:Please list any support the child is receiving:Please check appropriate box if applicable:Reading Below grade level At grade level Above grade level Math Below grade level At grade level Above grade level Spelling Below grade level At grade level Above grade level Writing Below grade level At grade level Above grade level 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 Poor posture, slouches SELDOM SOMETIMES OFTEN Tires easily, poor endurance SELDOM SOMETIMES OFTEN Awkward gross motor skills (i.e. hopping, climbing, skipping) SELDOM SOMETIMES OFTEN Fearful of heights SELDOM SOMETIMES OFTEN Awkward/hesitant on stairs SELDOM SOMETIMES OFTEN Poor balance SELDOM SOMETIMES OFTEN Bumps into chairs, walls, etc. SELDOM SOMETIMES OFTEN BASIC SENSORY FUNCTIONING:Pushes, shoves, hits or kicks when near other children SELDOM SOMETIMES OFTEN Dislikes being touched unexpectedly SELDOM SOMETIMES OFTEN Easily overwhelmed by too much noise, movement SELDOM SOMETIMES OFTEN Over or under reacts to pain SELDOM SOMETIMES OFTEN Craves spinning, fast movements; does not get dizzy SELDOM SOMETIMES OFTEN FINE MOTOR:Hand dominance RIGHT LEFT UNCLEAR Difficulty manipulating small objects (i.e. pegs, beads) SELDOM SOMETIMES OFTEN Difficulty handling clothing fasteners SELDOM SOMETIMES OFTEN Shaky or jerky hand movements SELDOM SOMETIMES OFTEN Atypical pencil grip SELDOM SOMETIMES OFTEN Lacks good control with crayons, pencils, or scissors SELDOM SOMETIMES OFTEN VISUAL PERCEPTION:Difficulty putting together puzzles SELDOM SOMETIMES OFTEN Limited drawing SELDOM SOMETIMES OFTEN Difficulty reproducing designs or letters SELDOM SOMETIMES OFTEN Poor spacing of work on paper SELDOM SOMETIMES OFTEN Reverse letters, numbers, or words SELDOM SOMETIMES OFTEN LEARNING BEHAVIOR:Unable to attend to task as long as classmates SELDOM SOMETIMES OFTEN Easily distracted SELDOM SOMETIMES OFTEN Wiggles a lot; can’t sit still SELDOM SOMETIMES OFTEN Disorganized, messy SELDOM SOMETIMES OFTEN Slow worker SELDOM SOMETIMES OFTEN Appears to have difficulty comprehending what is going on around him/her SELDOM SOMETIMES OFTEN SOCIAL-EMOTIONALBehavior annoys or bothers others SELDOM SOMETIMES OFTEN Impulsive SELDOM SOMETIMES OFTEN Lacks confidence (says “I can’t” or “too hard”) SELDOM SOMETIMES OFTEN Easily frustrated SELDOM SOMETIMES OFTEN Happiest playing alone SELDOM SOMETIMES OFTEN Difficulty making friends SELDOM SOMETIMES OFTEN Additional comments: