DEVELOPMENTAL QUESTIONNAIRE
Please Fill Out Completely
Today's Date:
Child's Name:
How old is your child?
Date of Birth:
MaleFemale
What are you concerned about?
---PDD/AutismAsperger’s SyndromeVisionHearingDevelopmental DelayLearning DisabilitiesSpeech & Language Delays
Parents
Parents are:MarriedNever MarriedSeparatedDivorcedDeceased
Age:
Does family have a history of speech and language difficulties?
YesNo
If yes, please explain:
If yes, please explain
Siblings
Male or Female?
Do siblings have a history of speech and language difficulties?
At Present
*All children must be up to date on all required immunizations prior to enrollment.
Does your child:
Wear glasses?
Have allergies?
If yes, please list:
Currently sees a physician for conditions other than regular check-up? Explain:
Takes Medications?
Medication
To Treat What?
Frequency
Side Effects
Seems to be emotionally and mentally healthy?
If no, explain:
Sees an orthodontist?
For what reason?
Have any feeding/swallowing difficulties?
Birth
Is the child adopted?
Length of Pregnancy:
Was the delivery normal?
Was the mother’s health good during the pregnancy?
During pregnancy, did the mother:
Smoke?
Drink Alcohol?
Use Drugs?
Child’s weight/condition at birth:
Development
Does your child have a history of ear infections?
If yes: Frequency
At what age did your child reach these developmental milestones?
Sat up alone
1 month2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year1 year, 1 month1 year, 2 months1 year, 3 months1 year, 4 months1 year, 5 months1 year, 6 months1 year, 7 months1 year, 8 months1 year, 9 months1 year, 10 months1 year, 11 months2 years2 years, 1 month2 years, 2 months2 years, 3 months2 years, 4 months2 years, 5 months2 years, 6 months2 years, 7 months2 years, 8 months2 years, 9 months2 years, 10 months2 years, 11 months
Dressed Self
3 years, 6 months4 years4 years, 6 months5 years5 years, 6 months6 years6 years, 6 months7 years7 years, 6 months
Crawled
Walked Alone
Toilet Trained
2 years2 years, 1 month2 years, 2 months2 years, 3 months2 years, 4 months2 years, 5 months2 years, 6 months2 years, 7 months2 years, 8 months2 years, 9 months2 years, 10 months2 years, 11 months3 years3 years, 6 months4 years4 years, 6 months5 years5 years, 6 months6 years6 years, 6 months7 years7 years, 6 months
Motor coordination is:
ExcellentGoodPoor
Behavior/Discipline
Does your child have playmates in the neighborhood?
Seems to be a leader or a follower?
LeaderFollower
Prefer to play with people or things?
PeopleThings
What seems to motivate your child?
What pleases you most about your child’s behavior?
What bothers you most about your child’s behavior?
Method of discipline used?
How often does your child need to be disciplined?
Discipline has been:
StrictLenientInconsistentAdequate
Age of first words:
3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year1 1/2 years2 years2 1/2 years3 years3 1/2 years4 years4 1/2 years5 years5 1/2 years Age of first sentences:---3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year1 1/2 years2 years2 1/2 years3 years3 1/2 years4 years4 1/2 years5 years5 1/2 years6 years6 1/2 years7 years7 1/2 years8 years
When did your child’s speech/language first concern you?
How has the family attempted to improve the child’s communication?
What do you think may have caused the problem?
Has your child been seen or evaluated by:
Speech-Language Pathologist?
Name:
Agency:
Date:
Developmental Psychologist?
Developmental Pediatrician?
Occupational Therapist?
**PLEASE ATTACH ANY OTHER SPEECH AND LANGUAGE AND/OR MEDICAL REPORTS THAT MAY BE PERTINENT TO YOUR CHILD’S THERAPY HERE AT THE CENTER**
****Effective 11/30/2020, the immunization protocol is suspended. When we begin to meet again in person, the immunization protocol will be back in effect.****
**PLEASE ATTACH DOCUMENTATION OF ALL VACCINATIONS IN THE FORM OF YOUR CHILD’S IMMUNIZATION RECORD OR A SIGNED STATEMENT FROM A MEDICAL DOCTOR**
IN ORDER FOR YOUR APPLICATION TO BE COMPLETE, YOU MUST PROVIDE ALL PREVIOUS TEST SCORES, SUCH AS ACHIEVEMENT'S TEST.