PC-Early Learning Questionnaire
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
My Child:
knows all of his/her upper case letters by name (not sound)?
*
Yes
No
knows all of his/her lower case letters by name (not sound)?
*
Yes
No
knows _______ many words by sight.
*
can read at the _______ grade level
*
Please add any other information related to attempts teaching reading that we should know.
has had their eyes checked?
*
Yes
No
wears glasses?
*
Yes
No
can identify numbers when shown in random order:
*
No numbers known
1-20
1-50
1-100
can count orally with 100% accuracy to:
*
Not able
1-10
1-15
1-20
1-50
1-100+
can accurately give me ______ objects when requested. Example: you say "Give me five crayons or ten pennies" and the correct amount is placed in your hand.
*
1-5 items
1-10 items
1-15 items
1-20 items
0 items
has been introduced to simple subtraction problems
Yes
No
Check all that apply:
My child:
*
knows the names of 6+ basic shapes.
understands what comes next in a sequential pattern.
can write numbers 0-20 without a model.
knows if a number is smaller/larger than another number between 1-20.
knows if a number is smaller/larger than another number between 1-100.
has been introduced to written addition problems.
has been introduced to written subtraction problems.
has more than five math facts memorized.
can tell time to nearest half-hour on an analog clock.
can do single-digit addition and subtraction problems with very little assistance.
does not know any shapes
List any learning or behavior labels your child has receive or you suspect:
*
Submit
Should be Empty: