The Child Development Network
Questionnaire for
Parents
Dr Otilie Tork
Your Child’s Name
Preschool / Daycare /
Kindergarten
How long has your child been
there?
Parent/Guardian 1 Name
Parent/Guardian 2 Name
If separated please indicate () □ Iftoyou are separated, we will need
discuss correspondence
arrangements with you.
Parent/Guardian 1 Occupation
Parent/Guardian 2 Occupation
What does your child enjoy, do well, and what do you like about
them?
Suite 7, The Terraces, 19 Lang Pde, Milton, 4064 PO Box 1536, Milton 4064
(07) 3369 3369 (07) 3369 3370 [Link] cdn@[Link]
Overall, how concerned (worried) are you about your child?
Not at all A little Moderately Quite a lot Extremely
Parent/
Guardian 1 1_____________2______________3_____________4______________5
Parent/
Guardian 2 1_____________2______________3_____________4______________5
What concerns you, and what don’t you understand about your
child?
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What would you like from us?
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Your child's health ()
Any concerns about your child’s health □ Yes □
currently? No
Any concerns about the pregnancy? □ Yes □
No
Any concerns about the birth and postnatal □ Yes □
period? No
Any accidents / injuries / serious illnesses in the □ Yes □
past? No
Has your child's hearing been checked? □ Yes □
No
If it has been checked, was it normal? □ Yes □
No
Has your child's vision been checked? □ Yes □
No
Is your child fully immunised? □ Yes □
No
Are there any other important medical issues? □ Yes □
No
What was the birth weight? _________ If premature, how many weeks?
___________
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As your child was growing up, were you concerned about ()
The first year? (e.g. hard to settle, poor weight □ Yes □
gain?) No
Early motor development (sitting, walking, □ Yes □
running, kicking)? No
Early language (talking and understanding)? □ Yes □
No
Early social development (eye contact, play, □ Yes □
friends)? No
Early learning (e.g. colours, shapes, drawing)? □ Yes □
No
Any other major concerns during early childhood? □ Yes □
No
The Family ()
Does anybody in the family (siblings, parents, □ Yes □
grandparents, aunts, uncles etc) have problems No
similar to, or the same as your child?
Does anybody in the family (siblings, parents,
grandparents, aunts, uncles etc) have different □ Yes □
problems, of a developmental, learning, No
behavioural, emotional or psychiatric nature?
Of any problems identified above, what in particular would you like
to discuss?
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Who have you consulted for your child’s difficulties?
(Remember to bring a copy of all written reports!)
Currently In the Past
Who?
() ()
Health Services
Paediatrician
Child Psychiatrist
Occupational
Therapist
Physiotherapist
Speech Pathologist
Psychologist
Social Worker /
Counselor
Education Services
School Guidance
Officer
Support / Remedial
Teacher
Home Tutor
Other
Who is your GP?
For any professionals identified, please summarise the involvement.
(When it started / ceased, how often, what was done)
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When you come to see us
Sensitive information
Is there sensitive information that you would prefer □ Yes
not to talk about in front of your child? □ No
If yes, we can discuss these issues while the child waits outside.
You may wish to bring a book or something for them to do while they
wait.
If they will need supervision, please bring somebody along to supervise
them.
Photography Consent
On occasion, we may take a photo of your child to
help us remember them, and this photo may be □ Yes
Dr Otilie Tork– Initial Parent Questionnaire (Preschool) Page 7 of 8
stored on our computer system. □ No
Do you or your child have any object to this?
Information from Third Parties
Sometimes we require information from third parties
such as school teachers, other health professionals,
and people that interact with your child.
Do we have your permission to contact these third
parties? □ Yes
□ No
Thank you for taking the time to complete this questionnaire.
Completed by ________________________ Date ___________________
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