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 NameLast Name
Date of Birth*

MonthDayYear
Gender*
If other, please elaborate during intake interview.
Name of Legal Guardians*

First NameLast Name
*

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

Area CodePhone Number
E-mail*
Mailing Address*

Street Address

Street Address Line 2

CityState

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 parentsstep motherstep fatheradoptive parentsnatural mothernatural fatherfoster parentsgrandparentsOther
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

:HourMinutesAM/PM Option
Wake Time

:HourMinutesAM/PM Option
Naps?

YesNoOccasionally
School History
Current Grade
School
District
Current school services:

head startsection 504 planspeech therapyoccupational therapyresource roomspecial education servicesPPCDearly reading program (Title I)physical therapyadaptive PEschool counselorself-contained classroominclusion servicesOther
If eligible, what is your child's special education eligibility?

Speech ImpairmentSpecific Learning DisabilityEmotional DisturbanceOther Health ImpairedAutismIntellectual DisabilityTraumatic Brain InjuryOther
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:

FailingBelow AverageAverageAbove Average
Written Expression:

FailingBelow AverageAverageAbove Average
Math:

FailingBelow AverageAverageAbove Average
Spelling:

FailingBelow AverageAverageAbove Average
Handwriting:

No ConcernsPoor spacingPoor letter FormationLetter ReversalsOther
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

WorseSameBetter
Get along with peers

WorseSameBetter
Behave with parents

WorseSameBetter
Play by self

WorseSameBetter
Work by self

WorseSameBetter
Behave in public

WorseSameBetter
Behave with sitters

WorseSameBetter
Behave at school

WorseSameBetter
How does your child relate to others?

affectionateannoyingcruelcuriouseasily angeredeasily embarrassedeasily misleadeasily upsetfearfulfightsfriendlyfun-lovinggenerousimpulsivejealouslazylonelymeanno friendsquietresentfulroughself-consciousselfishseriousshyshow-offsuspiciousteasestensetrustingwithdrawsOther
How does your child relate to his/her parents?

afraidangryasks for helpbossycomfortscooperativecriesdisobedienteasily controlledhelpfulhitsignoresobedientpoutsseeks attentionshares feelingstalks backtells liestemper tantrumstries to pleaseuncontrollableuncooperativewithdrawsyellsOther
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