SCHOOL QUESTIONNAIRE
2024/2025 SCHOOL YEAR ENROLLMENT
STUDENT'S NAME
*
First Name
Middle (optional)
Last Name
STUDENT'S DATE OF BIRTH
*
-
Month
-
Day
Year
PERSON COMPLETING THIS FORM
*
First Name
Last Name
RELATIONSHIP TO CHILD
PHONE NUMBER OF PERSON COMPLETING THIS FORM
EMAIL OF PERSON COMPLETING THIS FORM
MEDICAL/HEALTH HISTORY
HAS YOUR CHILD HAD ANY OF THE FOLLOWING HEALTH CONDITIONS?
Premature birth
Serious illness
Ear tubes
Recent illness
Full audiological evaluation
Speech therapy
Occupational therapy
Physical therapy
Other
None of the above
CHILD'S PRIMARY CARE PHYSICIAN
DEVELOPMENTAL MILESTONES
DOES YOUR CHILD...
GET DRESSED INDEPENDENTLY?
Yes
No
Sometimes
ACCEPT LIMITS WITHOUT GETTING UPSET?
Yes
No
Sometimes
OVERREACT OR HAVE TEMPER TANTRUMS?
Yes
No
Sometimes
GET FRUSTRATED EASILY?
Yes
No
Sometimes
USE THE BATHROOM INDEPENDENTLY?
Yes
No
Sometimes
STICK TO ONE ACTIVITY FOR AT LEAST 15 MINUTES AT A TIME?
Yes
No
Sometimes
PLAY WELL WITH OTHER CHILDREN?
Yes
No
Sometimes
USE WORDS RATHER THAN PHYSICAL ACTIONS?
Yes
No
Sometimes
AREAS OF OVERALL DEVELOPMENT
PLEASE CHECK ALL AREAS OF CONCERN
Health
Motor skills
Comprehension skills
Language skills
Hearing
Self-help skills
Vision
Social skills
None of the above
WHAT DO YOU WANT YOUR CHILD TO GET FROM HIS/HER SCHOOL EXPERIENCE?
IS THERE ANYTHING ELSE YOU WOULD LIKE TO SHARE WITH US?
*
SUBMIT
Should be Empty: