Age 3: Screening Questionnaire
Please fill out the sections that are relevant to your child. This will help us gather important information about your child's development.
Caregiver's Name
*
First Name
Last Name
Child's Diagnosis (if applicable)
*
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Contact Method
*
Phone call
Text
Email
Physical Therapy
Physical Therapy
1. Kicks a ball that is rolling directly to him/her
Yes
No
2. Balances on one leg with hands on hips for over 5 sec
Yes
No
3. Walks over a 20ft curved line, while staying on path
Yes
No
4. Step-hops multiple times
Yes
No
5. Jumps forward with 2 feet together
Yes
No
6. Bounces and catches a ball
Yes
No
7. Rides a tricycle around obstacles
Yes
No
8. Catches a large ball thrown at him/her
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Holds crayons with thumb and fingers (answer NO if holding crayon full fisted)
yes
no
2. Holds paper with one hand, while writing/coloring with opposite hand
yes
no
3. Completes 6pc puzzle (without a matching background)
yes
no
4. Folds paper in halves, three times and with good accuracy
yes
no
5. Cuts a circle with scissors
yes
no
6. Tries again challenging activities
yes
no
7. Puts own clothes correctly (front vs back)
yes
no
8. Takes turns when playing with peers
yes
no
9. Cleans up own spills
yes
no
10. Pours own milk into a bowl
yes
no
Additional Occupational Therapy comments or concerns:
Speech Therapy
Speech Therapy
1. What is your child's communication method?
Whines, screams, cries
Gestures (e.g. push, pull, grab, wave)
Produces all/most of these developing sounds clearly (p, b, m, k, g, w, h, n, t, d)
American Sign Language
AAC/Speech Generating device
Single words
Two word combinations (e.g. want milk, eat cereal, puppy eat, go bye bye )
Three word Phrases (e.g. Puppy drink water, daddy go park)
Full sentences
2. My child's speech is about 75-90% intelligible to most people
Yes
No
3. Understands most words that describe objects or people (e.g. fat dog, spotted kitten, rough board).
Yes
No
4. Able to take turns in a board game and play cooperatively
Yes
No
5. Remembers events and sequences of favorite stories and knows or anticipates what will happen next
Yes
No
6. Asks questions that begin with WHAT, WHEN, WHERE and is beginning to ask WHY
Yes
No
7. Uses subjective pronouns appropriately (he, she, they, us, we)
Yes
No
8. Maintains a topic of conversation by taking turns and/or commenting on what the other person says
Yes
No
9. Begins to understand the concept of "same" and "different"
Yes
No
10. Any feeding difficulties?
Transitioning from liquids to puree
Transitioning from puree to solids (soft, mechanical)
Coughs with solids/liquids
Choking or gagging
Reflux
Regurgitation of solids/liquid through nose
Difficulty with chewing
Picky eater
NG, J or G-tube fed
Additional Speech Therapy comments or concerns:
Applied Behavior Analysis
Applied Behavior Analysis
Please describe how your child communicates with you (words, pictures, signs, assistive technology). Example 1: My child can use 50 words to ask for items or activities. Example 2: My child typically pulls me towards the items they want.
Please describe any challenging behaviors your child has exhibited when faced with difficult situations such as but not limited to being told no or asked to complete a non-preferred task. Example 1: When I tell my child that it is time for a bath, they typically run away and refuse to come. Example 2: When my child loses a game, they typically will cry and throw the game pieces.
Please describe the main goals you have for your child.
Submit section
Submit
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