MIGDAS-2- Parent/Caregiver Questionnaire

Email:

example@example.com

Child's Name:

Age:

Gender:

School:

Grade:

Respondent:

8. Relationship to Child

9. Date Completed

Date

This questionnaire is designed to help gather information from the parent(s) or primary caregiver(s) of the child being evaluated. Please provide detailed descriptions and examples for each question.

Concerns

1. Describe your major concerns about your child at the present time.

Relationships

2. Who lives with your child at home? How does your child relate to different family members?

3. What other children does your child spend time with? How old are they? What types of activities do they do together? How do they get along?

4. Does your child prefer to spend time alone or with others?

Activites and Interests

5. What activities does your child like to spend the most time doing? Describe your child's special skills or areas of particular interest in as much detail as possible.

6. Describe your child's responses to sensory input and changes in his/her surroundings, including any preferences and aversions.

Food

7. What types of food does your child prefer?

8. What types of food does your child dislike?

9. If your child is bothered by specific foods, have you noticed what is bothersome, for example, specific textures, food touching other food on the plate, or food mixed together?

10. Does your child follow any dietary restrictions? Describe any specific changes in mood or behavior you've noticed since putting the dietary restrictions in place.

Clothing

11. Are there types of clothing your child prefers?

12. Is your child bothered by clothing, for example, tags seams in socks, long sleeves, tight or loose clothing, or type of material?

Tactile

13. What types of touch does your seek out, for example, deep pressure input, light touch, avoids touch?

14. Does your child frequently touch or hold objects?

15. Does your child pick at his/her skin or hair, or place his/her fingers, hair or other objects in his/her mouth?

Visual Details

16. Does your child seem to notice or comment on visual details that others do not pay attention to? Can you give an example?

17. How does your child react to changes in visual details, for example, if something is moved or rearranged in his/her room or elsewhere?

Noises

18. What types of noises bother your child? How does he/she react?

19. What types of noises does your child seek out?

Smells

20. Are there particular smells that your child dislikes or comments on as being bothersome?

21. Does your child ever explore objects by smelling them?

Sleep Patterns

22. What is your child's bedtime routine?

23. Does your child sleep through the night?

Body Boundaries

24. Does your child become upset when he/she perceives others to be standing too close or entering his/her personal space?

25. Does your child show a lack of awareness of personal space by standing too close or entering the personal space of others?

Crowded Places

26. How does your child react in crowded places?

Transitions Times and Changes in Routine

27. How does your child react to transition times, such as shifting away from his/her preferred activity to an activity you are directing your child to do?

28. How does your child react to changes in routines?

29. Does your child do better when you prepare him/her for changes in advance?

30. Do you ever prepare your child for a change in routine by presenting it in a written or visual format, such as a calendar or list?

Response to Pain

31. How does your child respond when he/she is hurt or has minor bumps or scrapes?

32. Describe how your child manages anger and frustration.

33. What situations trigger langer or agitation in your child?

34. How does your child express anger or agitation?

35. What helps your child to calm down when angered or agitated?

Emotions- Fear/Anxiety

36. What fears or anxieties, if any, does your child display?

Medications

37. Is your child taking any medications?

38. Describe the type and purpose of each medication.

39. How long has your child been taking each medication?

40. What changes in your child's behavior have you noticed since your child began taking each medication?

Developmental Milestones

41. Describe your child's developmental milestones.

42. Was there anything notable in your child's birth history?

43. Did your child experience any delays in the areas of walking, talking, or toilet training?

44. Did your child receive any early childhood interventions, such as speech therapy, occupational therapy, or physical therapy? If so, what therapy services were received?

45. Has your child had any physical health conditions or major accidents or injuries? If so, what type of treatment did he/she receive?

School Experience

46. Describe your child's school experience. What interventions or supports have worked well? What changes would you like to see put into place for your child?

47. Past Experience:

48. Current:

Current understanding or autism spectrum differences

49. What have you read or learned about autism spectrum disorder? What are your thoughts about autism spectrum differences in relation to your child?

Evaluation History

50. Describe any previous testing and the results.

Family History

51. Is there anyone in your immediate or extended family who has learning, social or other challenges?

Three words/qualities to describe child

52. What three words or qualities would best describe your child?

Closing Questions

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

54. What do you hope to gain from this evaluation?

55. Do you have any specific questions about the evaluation process?

56. Additional Notes:

MIGDAS-2- Parent/Caregiver Questionnaire

Instructions

Sensory Behaviors

Emotions- Anger/Frustration