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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? YesNo

If “no”, explain briefly:

Was your child delivered normally? YesNo

If “no”, explain briefly:

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

If “yes”, explain briefly:

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

If “no”, explain briefly:

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

If “no”, explain briefly:

Did your child experience any developmental delays? YesNo

If “yes”, explain briefly:

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

Is your child adopted? YesNo

Medical History

Does your child have any allergies? YesNo

If yes, please explain briefly:

Has your child had a serious illness? YesNo

If “yes”, explain briefly:

Has your child had a serious accident? YesNo

If “yes”, explain briefly:

Has your child ever been hospitalized?YesNo

If “yes”, explain briefly:

Has your child had any other medical problems or concerns? YesNo

If “yes”, explain briefly:

Does your child have sleeping problems? YesNo

If “yes”, explain briefly:

Does your child have eating problems? YesNo

If “yes”, explain briefly:

Does your child have problems with bed-wetting? YesNo

If “yes”, explain briefly:

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

If “yes”, explain briefly:

Physician(s) most recent visit:

Medications:

School/Education History

Has your child ever been held back a grade? YesNo

If “yes”, what grade(s):

Has your child ever been in special education? YesNo

If “yes”, what grade(s):

Has your child ever been in a resource room? YesNo

If “yes”, what grade(s):

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

If “yes”, what grade(s):

Has your child ever been suspended from school? YesNo

If “yes”, explain briefly:

Has your child ever had behavior problems in school? YesNo

If “yes”, explain briefly:

Has your child ever had poor or failing grades? YesNo

If “yes”, explain briefly:

Has your child ever had attendance problems?YesNo

If “yes”, explain briefly:

Has your child ever been home schooled?YesNo

If “yes”, explain briefly:

Hyperactivity/A.D.D.

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

If “yes”, explain briefly:

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

If “yes”, when and which medications?

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

If “yes”, explain briefly:

Social Relations

Does your child have trouble making friends? YesNo

Does your child have trouble keeping friends? YesNo

Does your child play mostly by himself/herself? YesNo

Does your child get picked on by other kids? YesNo

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

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

(Phone Number)

(Date)

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

March 24, 2020 2:04 pm PDT

Parent/Guardian Questionnaire Uploaded by OCP Documents - ocpdocs@oregoncp.org IP 10.0.10.40

March 25, 2020 5:00 pm PDT