Age 4: 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. Jumps forward 2ft with both feet
Yes
No
2. Kicks a ball after taking 2 steps to start
Yes
No
3. Walks 10 ft while carrying an object
Yes
No
4. Gallops for 10 ft
Yes
No
5. Hops on one leg for 10 ft
Yes
No
6. Throws a ball over 10ft distance
Yes
No
7. Swings back and forth independently
Yes
No
8. Walks over balance beam without losing balance
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Traces line around opposite hand
yes
no
2. Draws a person (at least eight body parts)
yes
no
3. Cuts pictures following general shape
yes
no
4. Knows personal information: parent's phone number/home address
yes
no
5. Obeys rules when playing games
yes
no
6. Avoids dangerous situations/objects/equipment
yes
no
7. Dresses independently
yes
no
8. Spreads PB&J with knife
yes
no
9. Uses towel to dry body after bathing
yes
no
10. Wipes self after toileting
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)
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
Produces all/most of these developing sounds clearly (p, b, m, k, g, w, h, n, t, d)
Speech is understandable, but makes mistakes with multisyllabic or complex words, such as "hippopotamus"
2. Points to pictures that represent a 2-3 sequence of event in a story
Yes
No
3. Answers simple questions, such as "What do you do when you are hungry?"
Yes
No
4. Points to or places objects in front, in back, around, through, by, beside or behind
Yes
No
5. Uses negative in sentences (e.g. "That is not my cup")
Yes
No
6. Uses regular past tense (E.g. walked, painted, washed)
Yes
No
7. Responds appropriately to "where" and "why" questions by giving a logical reason
Yes
No
8. Describes attributes of objects or items (e.g. that apple is red and round. It grows on trees")
Yes
No
9. Uses time events appropriately (today, yesterday, tomorrow)
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
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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