Oregon Community Programs

Parent/Guardian Questionnaire


Child’s Name:  Date of Birth:  

Your Name:  Relationship to Child:

Caregiver email:

School Name& Contact Person (if applicable):  

 

Early Development

Did you/birth mother have a normal pregnancy with your child?

 If “no”, explain briefly:

Was your child delivered normally?

If “no”, explain briefly:

Was your child prenatally exposed to drugs and/or alcohol?

If “yes”, explain briefly:

Did your child have normal motor development (crawling, walking)?

If “no”, explain briefly:

Did your child have normal cognitive development (speech, language)?

If “no”, explain briefly:

Did your child experience any developmental delays?

If “yes”, explain briefly:

At what point was your child first referred for service?:

Is your child adopted?

 

Medical History

Does your child have any allergies?

If yes, please explain briefly:

Has your child had a serious illness?

If “yes”, explain briefly:

Has your child had a serious accident?

If “yes”, explain briefly:

Has your child ever been hospitalized?

If “yes”, explain briefly:

Has your child had any other medical problems or concerns?

If “yes”, explain briefly:

Does your child have sleeping problems?

If “yes”, explain briefly:

Does your child have eating problems?

If “yes”, explain briefly:

Does your child have problems with bed-wetting?

If “yes”, explain briefly:

Has there been a serious accident or illness involving a parent?

If “yes”, explain briefly:

Physician(s) most recent visit:

Medications:

 

School/Education History

Has your child ever been held back a grade?

If “yes”, what grade(s):

Has your child ever been in special education?

If “yes”, what grade(s):

Has your child ever been in a resource room?

If “yes”, what grade(s):

Has your child ever had an I.E.P?

If “yes”, what grade(s):

Has your child ever been suspended from school?

If “yes”, explain briefly:

Has your child ever had behavior problems in school?

 If “yes”, explain briefly:

Has your child ever had poor or failing grades?

If “yes”, explain briefly:

Has your child ever had attendance problems?

If “yes”, explain briefly:

Has your child ever been home schooled?

If “yes”, explain briefly:

 

Hyperactivity/A.D.D.

Has your child ever been diagnosed hyperactive or attention deficit disorder?

If “yes”, explain briefly:

Has your child ever been on medication for hyperactivity or A.D.D?

If “yes”, when and which medications?

Have you or others ever wondered if your child was/is hyperactive?

If “yes”, explain briefly:

 

Social Relations

Does your child have trouble making friends?

Does your child have trouble keeping friends?

Does your child play mostly by himself/herself?

Does your child get picked on by other kids?

Does your child have frequent conflicts or fights with other kids?

Does your child tend to play with other children who are much older or younger?

 

(Phone Number)

 

(Date)

Leave this empty:

Oregon Community Programs https://www.oregoncommunityprograms.org
Signature Certificate
Document name: Parent/Guardian Questionnaire
Unique Document ID: b8d9a31a1a40f711a88855825d6e18d6bc9b9b16
Timestamp Audit
March 24, 2020 2:04 pm PDTParent/Guardian Questionnaire Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85
March 25, 2020 5:00 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 10:00 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:19 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:32 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85