Age 7: 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
*
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. Walks backwards heel-toe
Yes
No
3. Skips forward
Yes
No
4. Kicks a ball while moving/changing directions
Yes
No
5. Completes somersaults
Yes
No
6. completes one sit up
Yes
No
7. completes one push-up
Yes
No
8. Participates in skipping rope
Yes
No
9. Completes Jumping Jacks
Yes
No
10. Can ride bicycle without training wheels
Yes
No
Additional Physical Therapy comments or concerns:
Occupational Therapy
Occupational Therapy
1. Brushes teeth well
yes
no
2. identifies the value of coins and bills
yes
no
3. Uses fork/spoon well and uses knife to spread butter
yes
no
4. Pours liquids from a pitcher into a cup without spillage
yes
no
5. Completes dressing independently (no help for identifying front/back, inside-out/right side out)
yes
no
6. Gets food items needed for preferred meals
yes
no
7. Follows simple road safety rules
yes
no
8. Prepares cold snacks independently (chips, fruits, cereal, sandwhich)
yes
no
9. Completes homework in time
yes
no
10. Brings all school materials needed for homework
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 developing sounds clearly
Speech is understandable, but makes mistakes with multisyllabic or complex words
2. Makes predictions about stories
Yes
No
3. Understands figurative language (e.g. It's raining cats and dogs. hold your horses)
Yes
No
4. Begins to use cause and effect (If I do my homework, I can go outside and play)
Yes
No
5. Emerging use of irregular past tense and plurals
Yes
No
6. Uses non-linguistic and non-verbal behaviors (posture, gestures) appropriately and sustains topic in conversation
Yes
No
7. Uses details in description (e.g. I see a striped beach ball under the round table)
Yes
No
8. Uses adverbs regularly (E.g. They ran quickly).
Yes
No
9. Uses most morpheme markers consistently (e.g. plural s, and past tense -ed: The two girls walked to school)
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
Submit
Should be Empty: