Occupational Therapy Parent Questionnaire

 Occupational Therapy Parent Questionnaire

 Occupational Therapy Parent Questionnaire by Dr.Arunkumar.RM,

1. Identifying data

Child’s name:                                               Date of birth:

Address:                                                       Telephone:

Country of birth:

2. Reason for referral

Who suggested that your child should be assessed by an occupational therapist?

Why?

What do you feel are your child’s main difficulties?

3.  Family structure

Father’s name:                                               Occupation:

Mother’s name:                                             Occupation:

Siblings (brothers and sisters):

Parents’ marital status:

Please indicate whether the parents are separated or divorced, and who is thechild’s legal guardian and has custody:

Do you  have family member learning or physical disability

2. Medical history

Local doctor:           Address:          Specialist(s):                  Name:

Has your child suffered any illnesses or injuries? (Please describe.)

Has your child been admitted to hospital? (Please describe the child’s age, reason for and length of stay.)

Please describe your child’s general health.

Does your child suffer from any of the following?

	yes	No	Comments
Allergies
Colds
Ear infections
Epileptic fits
Car sickness

 Have the following been tested?

	yes	No	When	Prescription
Vision  Hearing

 

Has your child previously been assessed for or received occupational therapy? (Please describe.)

Has your child received any of the following services?

	yes	No	Comments
Speech and
language therapy
Physiotherapy
Other

Is your child under- or overweight?

Does your child have eating problems or any unusual food preferences? (Please describe.)

Do you have any concerns about your child’s diet?

4. Child development

 4.1 Early development Pregnancy

· Gestation period:

·  Medication:

· Smoking:

·  Birth weight:

· Health of mother at birth:

· Any difficulties? (Please specify):

· Feeding  -Breast /Bottle

·  Any feeding difficulties? (e.g. sucking, swallowing or chewing):

4.2 General development

How do you feel your child developed compared with other children?

SKILL	EARLY	AVERAGE	LATE	COMMET
Rolled over Sat Crawled  Walked  Played with toys Combined words

4. 2.1 Self-care

 4.2.1.1 Feeding 

SKILL	Cannot	needs help	Independent		Comments
Drink Feed Use a spoon Use a fork Use a knife Pour drinks

4.2.1.2 Dressing

	Yes	No	Comments
Undress
Dress self
Manage buttons
Do up a zip
Tie shoelaces

4.2.1.3 Personal Care

	Yes	No		Comments
Take self to the toilet
Wash hands
Shower/bath self
Clean teeth
Comb hair

 Toilet training

Age obtained bladder control:

Age obtained bowel control:

4.3 Gross motor skills

	Yes	No	Comments
Fall or lose balance
Appear clumsy
Ride a two-wheeler bike
Catch a ball well
Throw a ball well
Hop on either leg

4.4 Fine motor skills

	Yes	No	Comments
Prefer to use left/right hand
Draw shapes (e.g. circles and
squares)
Cut with scissors
Manage constructional games
(e.g. Lego or jigsaws)
Thread beads
Colour within the lines
Paste in without a mess

4.5 Language and communication

	Yes	No	Comments
Being understood by
others
Following instructions
Speech articulation

Other concerns re communication skills:

5.Behaviour and concentration

Describe your child’s behavior at home

Describe your child’s relationship with other family members.

	Yes	No	Comments
Overactive
Irritable
Aggressive
Bad tempered
Difficult to discipline
Quiet
Underactive
Withdrawn
Fussy
Easily distracted
Difficulty concentrating
Wants to go to bed early
Slow to go to sleep
Enjoys being touched and cuddled
Fearful of heights
Fearless of climbing
Memory

6. Social and emotional skills

	Yes	No	Comments
Friendly
Easy going
Talkative
Nervous
Shy
Teased

Does your child tease other children?

How does your child get on with: a) other children   b) adults

Does your child lack self-confidence or have low self-esteem?

7. School performance

Present school:                     Name of teacher:                 Class:

Previous schools attended (including nursery school):

Please describe any difficulties experienced or classes repeated.

Describe your child’s ability in the following:

(Rating scale: 1=poor, 2=fair, 3=average, 4=good, 5=excellent; circle appropriate number.)

Spelling
Reading
Mathematics
Hand Writing
Other Object
Sports Gross Motor Skills
Fine Motor Skills
Behavior In Class
Teacher Opinion Of Child Ability

 Do you want us to liaise with the school and/or send them a copy of the occupational therapy report? Yes/No.

8. General

When were you first aware that your child had a problem?

Who noticed it?

What do you feel may be the major contributing factor(s)?

Outline what others have said about your child’s problem(s):

What are your child’s assets/good points? (List at least three.)

What are your child’s goals?

What are your goals for your child?

Do you have any further comments or concerns, including your opinion regarding the reason for this referral?

Please provide or attach any additional information that you feel will assist us inunderstanding and helping your child.

Questionnaire completed by:

Relationship to child:

Signature:

Date: