Prek Evaluation Center Parent Questionnaire

SCHOOL DISTRICT OF MANATEE COUNTY
THE EVALUATION CENTER
6423 9th Street East, Bradenton,Fl. 34203 Mailing Address: P.O. BOX 9069, Bradenton, FL 34206-9069 (941) 721-2300 Fax: (941) 753-0958
Parent Questionnaire
Today’s Date:

Month Day Year
Date
Name(s) of person(s) completing this questionnaire
Relation to child:
Please complete this questionnaire as much as possible. The information provided will help us understand your child’s current level of functioning and will help us in planning appropriate evaluation procedures.
CHILD’S INFORMATION
CHILD’S NAME (LAST, FIRST)
DATE OF BIRTH (DOB)

Month Day Year
Date
BIRTH CITY/STATE
GENDER
Address

STREET ADDRESS

Street Address Line 2

City STATE

ZIPCODE
Child lives with: (i.e. mother, father, both parents, guardian)
Child lives with:

Mother and Father Mother Father Relative Foster Care/Guardian
HOME PHONE
EMAIL
Marital Status of Parents
MOTHER’S/GUARDIAN’S NAME
LEVEL OF EDUCATION/OCCUPATION
MOTHER’S CELLPHONE NUMBER
MOTHER’S WORK PHONE NUMBER
FATHER’S/GUARDIAN’S NAME
LEVEL OF EDUCATION/OCCUPATION
FATHER’S CELLPHONE NUMBER
FATHER’S WORK PHONE NUMBER
School child will attend Kindergarten:
Referred By:
Please list the people living in your home (Name, Relationship to Child, Age, Current school/Grade level)
Is child of Hispanice, Latino, or Spanish origin?

YES NO
Race (Check all that apply)

White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander
Agencies that may have seen your child before:

Safe Children Coalition/Dept of Children & Families All Children’s Hospital Manatee Memorial Hospital Manatee Hearing & Speech Blake Medical Center Early Learning Coalition Early Steps Lakewood Ranch Medical Center Manatee Glens
YOUR CHILD’S PHYSICIAN
OTHER MEDICAL SPECIALISTS
CURRENT CONCERNS
What are your areas of concern?

Speech Fine/Small Hand Coordination Behavior Language Gross/Big Muscle Coordination Learning Other
Has your child had a Speech/Language, Physical Therapy, Occupational Therapy, Psychological, Developmental, Neurological, or Orthopedic evaluation within the last six months?

Yes No
If yes, which one? Where? When?
Is your child currently receiving therapy? If yes, name of Agency?
Is your child currently receiving therapy? If yes, name of Agency?
Has your child been diagnosed with a medical condition? If yes, please explain.

No Yes
Medical condition (from question above)
What Information About Your Child Would You Most Like to Gain From This Evaluation?
Are there any family members or relatives who have or had any of the following?

Special education Epilepsy Vision Impairment Learning Disability Speech Therapy Hereditary Diseases Hearing Impairment Attention Deficit Disorder Autism
How would you describe your child's diet?

Regular (all foods allowed; no known food allergies or dietary restrictions) Pureed (requiring very little chewing ability) Mechanical Altered (requiring some chewing) Difficulty Swallowing Picky eater with exceptions
List food allergies/dietary restrictions:
SPEECH, LANGUAGE, VISION AND HEARING HISTORY
Language(s) Spoken in The Home:
Language(s) Spoken by The Child:
What Is the Child’s Dominant Language?
How would you describe the child’s primary method(s) of communication?

Looking at objects Pointing/Gestures Single words 2-3 Word Phrases Sentences
Which of the following best describes your child's speech?

Nonverbal Easy to understand (90% or better) Difficult for family to understand (less than 50%) Difficult for others to understand (Less than 50%)
Indicate with a check any/all areas of difficulty:

Understanding/Following Directions Being Understood Making requests Describing events
How does your child react when he/she is not understood?
Does your child:

Take a pacifier Suck a thumb Use a bottle
Has your child ever talked better than he/she does now?

Yes No
If no to question above, please explain
Has your child ever had an ear/hearing examination or treatment?

Yes No
Results of hearing examination/treatment:
How many ear infections has your child had?

1-2 3-5 6-10 10 or more
Has your child worn Pressure Equalization Tubes (PE Tubes)?

Yes No
How long has the child had tubes?
Has your child ever had a vision examination or treatment?

Yes No
If yes, Where? When? Who was the doctor? What were the results?
Does your child wear glasses?

Yes No
Does your child have eyes that turn in or turn out?

Eyes turn in Eyes turn out No
HEALTH AND DEVELOPMENTAL HISTORY
Baby’s weight at birth
Which pregnancy was this child?
Was the baby full term or premature?

Full term Premature
If premature, how many weeks gestation?
How was the baby born?

Natural C-Section
If the birth was natural, was it completed with:

Forceps Natural Vacuum Extraction N/A
Were there any illnesses or anything unusual about your pregnancy with this child?
Complications at Birth: (Check any that apply)

Required Oxygen (Trouble Breathing) Jaundice Blue Color Birth Injuries Irregular Heart Rate Other
If Other, please explain:
How long did your child remain hospitalized following birth?
Do you notice, or has a doctor reported, any of the following in your child?

Asthma Nightmares Seizures Allergies (Sinusitis, food, etc) Heart Trouble Cleft Lip/Palate Cerebal Palsy Orthopedic Problems Diabetes Tonsilitis Frequent Fevers Feeding Problems Other disorders such as meningitis, encephalitis, hepatitis, MRSA, etc
Has your child ever been hospitalized? Explain
Has your child ever had the following accidents/injuries:

Falling/Hitting Head Near Drowning Abuse/Neglect Loss of consciousness Car accident Other
If Other, please explain:
Has your child had any surgeries?

Yes No
If yes, what surgery?
Child's current medication(s) - Name and reason:
Developmental Milestones
Does your child seem overly awkward, uncoordinated or clumsy?

Yes No
Does your child lose their balance or fall easily?

Yes No
Does your child display hand preference?

No Yes - Left hand Yes - Right hand
If you respond "No" to any of the following questions, please use the Other field to state the age of the child at the time the milestone was achieved
Did your child hold his/hear head up by 4 months?

Yes No
Sat unassisted by 6 months

Yes No
First crawl by 12 months

Yes No
First walk alone by 16 months

Yes No
Toilet trained by 3 years

Yes No
Age child said Mama/Dada
Age child said words other than mama/dada:
Indicate with a check mark any/all areas of difficulty:

Zippers/Buttons Hopping/jumping Dressing Coloring Undressing Playing Safely Brushing Teeth Eating with utensils Throwing ball Sitting at table Walking/Running/Jumping Walking up/down stairs Transferring objects from hand to hand Building tower with blocks Balancing/hopping on one foot
BEHAVIOR/SOCIAL DEVELOPMENT
Please indicate any/all that apply to your child:

Overly Active Underactive Very Shy/ Overly quiet Poor Eye Contact Poor Memory Aggressive/Destructive Friendly Prefers to Plays Alone Avoids group plays Easily Frustrated Falls/trips frequently Difficulty with Transitions Appropriate turn taking skills Appropriate use of objects Difficulty separating from parent Difficulty concentrating Plays with toys appropriately
During your child's life have there been any changes in the family situation (such as a change in parents' marital status, frequent moves, death, etc?

Yes No
Does your child get along with other children? If no, please describe:
Does your child have any behavior problems that concern you? If yes, explain:
How do you handle your child's misbehavior? (Ex: Time out, ignore, spanking, etc)
Does your child have any fears that concern you?

Yes No
List your child's fears
What time does your child go to bed?
What time does your child wake up?
Does your child sleep through the night?

Yes No
Does your child have any sleeping problems such as:

Snoring Night terrors Sleep walking/talking?
Does your child do anything that you think is unusual or not typical? Explain:
What does your child enjoy doing?
What toys interest your child?
Has your child ever been to a nursery, ,daycare, or preschool center? If so, please list the most recent centers and list the length of time the child attended. If your child is currently in the center, please mark as current.
General Information
How do you view your child’s development (including motor coordination and social/emotional development) as compared to other children of the same age?
Please describe three or four things about your child that you consider to be strengths (things that your child does well, personality traits, etc).
Is there any additional information that you feel is important to better understand your child?
When receiving printed information from us, would you prefer to be contacted by US mail or email?
I certify that I am the legal guardian and that I can exercise all parental rights for said child.
By typing your name in this box, you are digitally signing this document and authorizing the Prek Evaluation Center to use this document for the referral process.
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SCHOOL DISTRICT OF MANATEE COUNTY

THE EVALUATION CENTER

Parent Questionnaire

CHILD’S INFORMATION

CURRENT CONCERNS

SPEECH, LANGUAGE, VISION AND HEARING HISTORY

HEALTH AND DEVELOPMENTAL HISTORY

Developmental Milestones

BEHAVIOR/SOCIAL DEVELOPMENT

General Information