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Parent Questionnaire

Contact Information
Name of Child:

Name your child likes to be called:

Child’s Date of Birth:

Age of Child:

Allergies (food or other):

Current Medications:

Name of Pediatrician:

Name of Dentist/Orthodontist:

Any specialty or other doctors that care for your child:

Parent(s) Name(s):

Marital Status of Parents:

Primary Phone Number:

Email:

Street Address:

City, State, Zip:

Names and ages of those living at home with the child:

Father’s Occupation:

Mother’s Occupation:

What are your top 3 primary concerns regarding your child’s performance and/or
development?

37278 Market Place Drive ๏ Prairieville, LA 70769 ๏ 225-744-1717

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Have there been any recent stresses or crises that have occurred in the last few years? If so,
please explain.

Medical/Developmental History
Please describe mother’s general health during pregnancy (illnesses, accidents, medications,
precautions, etc.):

Please describe any complications during pregnancy, labor, or delivery:

Did your child require a NICU stay? If so, how long and for what problems/interventions?

Does your child have any current diagnoses? If so, what?

Has your child had any surgeries or invasive medical procedures? Is yes, what type and when?

Describe any major accidents or hospitalizations:

Has your child received previous therapies including but not limited to occupational, speech,
physical or feeding therapy?

Please provide the approximate age at which your child began to do the following activities:

 Roll:
 Sit unsupported:
 Crawl:
 Walk:
 Feed self:
 Toilet:
 Use single words (e.g., no, mom, etc.):
 Combine words (e.g., me go, daddy shoe, etc.):
 Engage in conversation:

Pertinent Previous Testing and Therapeutic Intervention

Please list other professionals currently involved with your child’s care (Psychologist,
Neurologist, Speech Language Pathologist, Occupational Therapist, Ear Nose Throat Doctor,
tutors etc.)

Name:_______________________________ Title:_______________________________
Name:_______________________________ Title:______________________________
Name:_______________________________ Title:_______________________________

37278 Market Place Drive ๏ Prairieville, LA 70769 ๏ 225-744-1717

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Was your child ever evaluated for early intervention or by a child study team through programs
such as Early Steps, Leblanc Special Services, or a school system? If so, please describe.

Does your child wear glasses, contacts, and/or hearing aids? If not, are they any concerns with
your child’s vision and/or hearing?
Does your child have any adaptive or durable medical equipment such as a walker or orthotics?
Communication
Does your child have difficulty communicating?

How does your child primarily communicate (gestures, single words, short phrases, sentences,
conversation)?

Describe your child’s response to sound (e.g., responds to all sounds, tolerate loud noises,
responds to loud sounds only, inconsistently responds to sounds, etc):

Does/did your child ever use a pacifier/suck thumb or have an attachment to any other objects
they put in their mouth? If yes, describe use (how often and under what conditions).

When did the child discontinue using the pacifier/thumb sucking?

Feeding
Are there any concerns with feeding?

Are there or have there been any feeding or eating problems (e.g., any problems with sucking,
tolerating specific food textures, swallowing, drooling, chewing, etc.)? If yes, please describe.

Education History
Did / does your child attend preschool? Where, how many days/week, full/half days?

Does your child currently attend school? If not, who cares for the child during the day?

Where does your child attend school? What Grade?

Has his/her teacher reported any concerns to you? Please describe.

Have you reported any concerns to the teacher? Please describe.

How is your child doing academically (or pre-academically)? Please comment on reading,
written language, and math specifically.

Does your child like school?

37278 Market Place Drive ๏ Prairieville, LA 70769 ๏ 225-744-1717

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Please indicate your child’s educational setting and services. Circle all that apply. Where
applicable, indicate how many times per week, duration of sessions and group or individual.
 Regular Education
 Fully mainstreamed or Partially mainstreamed (for:____________________)
 Self-Contained Class
 Specialized reading curriculum
 1:1 aide
 Resource Room (for:_____________________)
 ABA
 Speech-Language Therapy
 Occupational Therapy
 Physical Therapy
 Adaptive PE
 Social Skills

Social History
Does your child live with both parents?

With whom does your child spend most of his/her time during the week? Relationship to child?

Is English your child’s primary language? Yes / No. If no, what other languages does the child
speak?

How does your child interact with others (e.g., shy, aggressive, inflexible, etc.)?

Does your child make friends easily? Yes / No

Does your child have more success interacting with adults than peers? Yes / No

Do you have any concerns about your child’s social skills or ability to make/keep friends? Please
describe.

Current Functioning
What are your child’s interests or favorite things?

Please describe your child’s personality.

What are your child’s strengths?

What are your child’s challenges?

Please tell us about your child’s coordination with handling small objects and handwriting.

37278 Market Place Drive ๏ Prairieville, LA 70769 ๏ 225-744-1717

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Does your child have difficulty with movements such as walking, running, or participating in
activities that require coordinated use of muscles?

How does your child handle transition to new people and situations?

How much screen time does your child receive on average during the week and weekends?

Does your child have any unusual behaviors? Describe.

Is there anything else you would like us to know about your child?

Miscellaneous
Are you familiar with Masgutova Neurosensorymotor Reflex Integration (MNRI)? What prior
experience do you have with MNRI?

How did you hear about Pediatric Therapy Solutions?

Date Completed: ____________________________________________

Person completing this form:_________________________________
Relationship to child: _________________________________________

37278 Market Place Drive ๏ Prairieville, LA 70769 ๏ 225-744-1717