SDMC Preschool Screening Questionnaire

School District of Manatee County

Preschool Screening Questionnaire
Preschool Screening Questionnaire

6423 9th Street East, Bradenton, Fl. 34203 Mailing Address: P.O. BOX 9069, Bradenton, FL 34206-9069 (941) 721-2300 Fax: (941)753-0958
Please take a few moments to introduce your child to us through this questionnaire.

This form has two parts that ask for information about your child:

Part 1: Personal background information about your child.

Part 2: Developmental Information about your child.
Please read through the form and respond to all items as carefully as you can. You are an important source of information about your child. The information and answers that you provide enable us to better understand the whole child. We greatly appreciate your time in completing this form and look forward to working with you and your child.
Child's Name (First & Last)*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Primary Language of family*
Primary Language of child*
Race (Check all that apply)*

WhiteBlack or African AmericanAsianAmerican IndianNative Hawaiian or Pacific Islander
Is child of Hispanic, Latino or Spanish Origin?*

YesNo
Name of Mother (First/Last)*
Mothers Occupation*
Name of Father (First/Last)*
Fathers Occupation*
Name of Guardian (First/Last)
Address*
City*
State*
Zip*
Home Phone*
Cell Phone*
Email address*
example@example.com
Person completing this survey:*

MotherFatherGuardianOther
If other to question above, please specify:
Living Situation
1. Who does your child live with? (Check all that apply)*

MotherFatherMother's PartnerFather's PartnerStepfatherStepmotherGrandmotherGrandfatherFoster FamilyOther
If Foster family: Case worker's name and phone #
If you marked Other (specify):
2.Is the child adopted?*

YesNo
3. If your child is adopted at what age did he/she join the family?
Siblings
Does your child have brothers or sisters?*

YesNo

Sibling Information

Rows	Name	Age	Name of school attending	Does the child live at home with your preschooler?
Sibling 1
Sibling 2
Sibling 3
Sibling 4

5. What are your concerns about your child's education and development?*
6. Has your child attended a preschool/ daycare?*

YesNo
If yes, for how long?
7. Is your child attending daycare/preschool full time or part time?
8. What is the name and location of our child's preschool/daycare?
Preschool or Daycare contact person's name
9. Has your child ever been asked to leave a daycare/preschool facility?*

YesNo
If yes, please explain
10. What school do you plan to send your child to for Kindergarten?*
Home Situation
11. When was the last time you moved?*
12. How often have you moved in your child's life?*
13. Have any of the following occurred?
Parents separated or divorced*

YesNo
If yes, when?
A death or major loss*

YesNo
If yes above, Who/When
Other major events that may have upset your child with corresponding dates?
14. Has your child reacted to any of the above situations with behaviors that concern you?
Type a question
15. Are there any family circumstances that you would like the evaluators/school to be aware of?*
Part 2: Developmental Information

General Information
16. Was the child a full-term baby?*

YesNo
If NO, at how many weeks gestation was he/she born?)
17. Were there any complications with the pregnancy or at birth?*

YesNo
If YES explain
18. Did your child stay in the NICU?*

YesNo
If YES, explain:
If YES, how long?
19. How long was the child in the hospital after birth?
20. What age did your child crawl on hands and knees?*
21. What age did your child start walking?*
22. What is your child's bedtime?*
Does your child sleep through the night?*

YesNo
23. Has your child received services through Early Steps?*

YesNo
24. Has your child seen an optometrist or ophthalmologist?*

YesNo
25. Does your child wear glasses?*

YesNo
26. Do you suspect your child has a vision problem?*

YesNo
Comments on vision concerns:
27. Do you suspect your child has a hearing problem?*

YesNo
Comments on hearing concerns:
28. Is your child under the care of an audiologist or ear, nose and throat (ENT) specialist?*

YesNo
29. Has your child had frequent ear infections?*

YesNo
30. Has your child had ear tubes inserted?*

YesNo
If YES, at what age(s)?
31. Does your child speak loudly?*

YesNo
32. Does your child have a medical diagnosis?*

YesNo
If YES, please describe:
33. Has your child ever been hospitalized?*

YesNo
If YES, please explain:
34. Has your child ever had surgery?*

YesNo
If YES, what surgery/surgeries?
35. Does your child take prescription medications on a routine, daily basis?*

YesNo
If YES, please list medications
36. Does your child have any allergies?*

YesNo
If YES, please list allergies:
37. Does your child have an EPIPEN?*

YesNo
38. Does your child use an asthma inhaler?*

YesNo
39. If your child has had evaluations/assessments completed, please check the type

Cognitive or Developmental examPsychological examNeurological exam
If your child has had one of the above exams, please describe the reason(s):
Name and location of person(s) who administered the exam
40. Has your child ever experienced a major psychological trauma?*

YesNo
41. Other medical information, if applicable
42. My child has had a speech and language evaluation.*

YesNo
If YES, did he/she receive therapy?

YesNo
If yes, for how long?
43. My child currently receives speech and language therapy.*

YesNo
Therapist's name/agency
44. My child will point to objects/pictures when I name them.*

YesNo
45. How does your child communicate his/her wants/needs?*
46. My child uses 50+ words to communicate.*

YesNo
Examples of words:*
47. My child puts at least two words together.*

YesNo
Examples of 2 word utterances: *
If YES to Question 47, please answer questions 48-50 below:
48. I feel my child pronounces words about as clearly as other children the same age.

YesNo
49. My child is generally understood by people outside the family.

YesNo
50. I find myself restating what my child has said to others.

YesNo
Gross Motor Information
52. My child can independently: (check all that apply)*

Throw or catch a ballKick a ballGo upstairs with alternating feetGo downstairs with alternating feetHop on one footBalance on one foot for 3-5 secondsHop on two feet
53. My child has difficulty: (check all that apply)*

Transitioning over different surfaces (level vs unlevel)Walking/running over unlevel surfacesNavigating obstacles (trips/falls often)Climbing on playground equipment
54. My child has had a physical therapy evaluation.*

YesNo
If YES, did he/she receive therapy?

YesNo
For how long?
55. My child currently receives physical therapy.*

YesNo
Therapist's name/agency
Sensory Information
56. My child is fearful of loud noises.*

YesNo
57. My child does not like crowds.*

YesNo
58. My child is a picky eater does not like certain food textures, colors, etc*

YesNo
59. My child becomes overwhelmed in new situations.*

YesNo
60. Certain clothing, tags, different materials, etc bother my child.*

YesNo
61. My child will run off through doors, in long corridors, etc*

YesNo
62. My child does not seem aware of pain and/or danger.*

YesNo
If YES, please explain
Fine Motor Information
63. My child can hold a crayon and draw/color with it.*

YesNo
64. My child can string beads.*

YesNo
65. My child can snip with scissors.*

YesNo
66. My child can copy a horizontal line, a vertical line and a circular shape.*

YesNo
67. My child has had an occupational therapy and/or sensory evaluation.*

YesNo
If YES, did he/she receive therapy?

YesNo
For how long?
68. My child currently receives occupational therapy.*

YesNo
Therapist's name/agency
69. My child sticks to one activity for at least 5 minutes at a time not including computer or TV.*

YesNo
70. My child perseverates or excessively over-focuses on things or ideas.*

YesNo
71. My child exhibits impulsive behaviors.*

YesNo
72. My child has been diagnosed with ADD or ADHD.*

YesNo
Social Development Information
73. If I say "look" and point, my child will look where I'm pointing.*

YesNo
74. My child has opportunities to play with other children his/her own age.*

YesNo
75. My child easily separates from parents.*

YesNo
76. My child can take turns.*

YesNo
77. My child gets along well with other children.*

YesNo
78. My child is fearful/anxious and worries a lot.*

YesNo
79. My child tolerates changes in routine.*

YesNo
80. Does your child exhibit any serious behavior problems?*

YesNo
Check all behaviors that apply:

Defiance of adults/non-compliantExcessive, long-lasting tantrumsBitingAggressive/violent behavior towards othersOther
If other, please describe:
81. What is your child's reaction to stress? (Check all that apply)*

CriesHeadacheStomachacheBitesOther
If Other, Describe:
82. Are there challenges with behavior mangement at home?*

YesNo
If YES, what is the most effective in establishing acceptable behavior?
My child's strengths are: *
My child continues to need assistance with: *
Please list any additional information that you feel is important regarding your child
Date Completed *

MonthDayYear
Date
Should be Empty:

School District of Manatee County

Living Situation

Siblings

Home Situation

Part 2: Developmental Information