Re-Evaluation Update Parent Questionnaire

Parent Questionnaire for Children and Adolescents: Re-Eval Update
Please answer the following questions carefully and completely. Your answers will help us greatly in our understanding of your child. The questionnaire will be reviewed with you, so it will be possible to discuss your answers.
Child's Name *

First Name Last Name
Date of Birth *

Month Day Year
Gender *
If other, please elaborate during intake interview.
Name of Legal Guardians *

First Name Last Name
*

First Name Last Name
Name of Person Completing Form *
Relationship to Patient *
Phone Number: *

Area Code Phone Number
E-mail *
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Current Concerns

Please list, in order of urgency, the problems your child is experiencing at this time.
A.
B.
C.
D.
E.
Family Situation

Who is the child currently living with?
Select all that apply

both natural parents step mother step father adoptive parents natural mother natural father foster parents grandparents
Siblings at home
Ages of siblings
Medical Updates
Has your child had any serious illnesses, injuries, or hospitalizations since the previous evaluation?
If yes, please describe (age and description)
Any new medical concerns?
Physician who referred my child for evaluation
Current medications and past medications since last evaluation:
Current therapies and past therapies since last evaluation:
Results of most recent hearing and vision exam:
Vision:
Hearing
Please describe your child's present eating habits. Note any problems or concerns.
Please describe your child's present sleep habits. Note any problems or concerns in going to sleep, sleeping alone, night awakenings, length of sleep, nightmares, sleep walking, etc.
Usual Bedtime

: Hour Minutes AM/PM Option
Wake Time

: Hour Minutes AM/PM Option
Naps?

Yes No Occasionally
School History
Current Grade
School
District
Current school services:

head start section 504 plan speech therapy occupational therapy resource room special education services PPCD early reading program (Title I) physical therapy adaptive PE school counselor self-contained classroom inclusion services
If eligible, what is your child's special education eligibility?

Speech Impairment Specific Learning Disability Emotional Disturbance Other Health Impaired Autism Intellectual Disability Traumatic Brain Injury
Please describe any academic subjects addressed through special education accommodations or modifications.
Please rate your child's current acadmic performance in the following areas:
Reading:

Failing Below Average Average Above Average
Written Expression:

Failing Below Average Average Above Average
Math:

Failing Below Average Average Above Average
Spelling:

Failing Below Average Average Above Average
Handwriting:

No Concerns Poor spacing Poor letter Formation Letter Reversals
Please describe any academic or school problems your child is currently experiencing:
Has your child had any school testing since the previous evaluation? If so, by whom, and when?
Social Functioning
Compared to other children of your child's age, how well does your child:
Get along with siblings

Worse Same Better
Get along with peers

Worse Same Better
Behave with parents

Worse Same Better
Play by self

Worse Same Better
Work by self

Worse Same Better
Behave in public

Worse Same Better
Behave with sitters

Worse Same Better
Behave at school

Worse Same Better
How does your child relate to others?

affectionate annoying cruel curious easily angered easily embarrassed easily mislead easily upset fearful fights friendly fun-loving generous impulsive jealous lazy lonely mean no friends quiet resentful rough self-conscious selfish serious shy show-off suspicious teases tense trusting withdraws
How does your child relate to his/her parents?

afraid angry asks for help bossy comforts cooperative cries disobedient easily controlled helpful hits ignores obedient pouts seeks attention shares feelings talks back tells lies temper tantrums tries to please uncontrollable uncooperative withdraws yells
Please describe your child's special strengths, talents, and abilities.
Please describe any unusually positive or negative relationships this child has with important people in his or her life.
Please provide any additional information that will assist the examiner in obtaining relevant information regarding your child's difficulties.
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Parent Questionnaire for Children and Adolescents: Re-Eval Update

Current Concerns

Family Situation

Medical Updates

School History

Social Functioning