Age 5: 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. Walks up and down stairs carrying books/toys without help
Yes
No
2. Runs through obstacle course
Yes
No
3. Skips forward
Yes
No
4. Maintains balance on a trampoline
Yes
No
5. Completes somersaults
Yes
No
6. completes one sit up
Yes
No
7. completes one push-up
Yes
No
8. Hangs from monkey bars
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Draws a picture of a familiar person, dog or object
yes
no
2. Completes 12 pc puzzle
yes
no
3. Cuts complex shapes with scissors
yes
no
4. Plays group games following rules
yes
no
5. Knows birth date
yes
no
6. Initiates appropriate topics of conversations
yes
no
7. Looks both ways when crossing the street
yes
no
8. Walks on sidewalk independently and without constant reminders
yes
no
9. Ties shoe laces independently
yes
no
10. Zips up Jackets independently
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. Makes facial expression appropriate to material (e.g. smile at someone's joke, look amazed when it's a surprise)
Yes
No
3. Understands time sequences (for example, what happened first, second, or third)
Yes
No
4. Uses compound sentences with more than one main clause (e.g. clauses such as "and", "but", "or")
Yes
No
5. Answers questions like: What did you have for lunch today?
Yes
No
6. Understands quantity concepts such as (one, some, rest, all, more, most)
Yes
No
7. Uses possessive pronouns (hers, his)
Yes
No
8. Describes objects, people or animals
Yes
No
9. Begins to understand rhyming
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 button
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