Halton and St Helens Division
Woodview Child Development Centre
Crow Wood Lane
Widnes
Cheshire
WA8 3LZ
Tel: 0151495 5400
Web: www.bridgewater.nhs.uk
Parent/Carer Questionnaire
Please complete this questionnaire as fully as possible.
Child’s Details
Name:
Date of Birth:
Home Address:
Telephone:
Ethnic Origin:
Religion:
First Language:
School Address:
Year:
Class:
G.P. Name and address:
Telephone:
Parent/Carer Name:
Please provide details of who has parental responsibility for child:
1
Ref: MS1a (13).doc
Birth History
Birth Weight: _________________
Please circle any of the following details, which relate to the birth of your child.
Premature Delivery
(Before 36 weeks)
Caesarean Section
Difficult Labour
Full Term Delivery
Forceps Delivery
Long Labour
Late Delivery
Ventous Delivery
Short Labour
Induced Labour
Complications
Comments:______________________________________________________________
_________________________________________________________________________
Developmental Milestones
Please indicate the age that your child reached the following milestones (if known)
Rolling _________________________
Crawling ________________________
Standing _______________________
Walking _________________________
Talking _________________________
Writing _________________________
Has your child been diagnosed with any medical condition
If Yes, please give details:
Yes No
Is your child known to any other professionals
(e.g. audiologist, orthoptist, CAHMS, please list)
Yes No
Does your child have any allergies
If Yes, please give details:
Yes No
2
Ref: MS1a (13).doc
Sensory History
Please circle any of the following activities that your child STRONGLY DISLIKES
Funfair rides
Games with eyes closed
Hair washing
Fast rides
Rough and tumble play
Brushing teeth
Off ground activities
Crowded places
Nails cut
Using an escalator
Certain smells
Messy play (e.g. clay)
Lifts
Certain foods
Hands/Face washing
Car journeys
Being tipped backwards
(e.g. to wash hair)
Certain textures
Noisy places
Comments: _______________________________________________________________
_________________________________________________________________________
Functional Skills – Activities of Daily Living
Please circle any of the following activities that your child has DIFFICULTY with:
Undressing/Dressing
Eating/Drinking
Using the toilet
Buttons
Opening packets
Bathing/Showering
Zips
Using cutlery
Washing hair
Shoelaces
Washing hands
Drying body
Comments: ______________________________________________________________
_______________________________________________________________________
3
Ref: MS1a (13).doc
Functional Skills - Play
Please circle any of the following that your child has DIFFICULTY with:
Playing in groups
Mixing with others
Fine motor games
Team games
Gross motor games
(e.g. running, jumping,
hopping, skipping)
Construction games
(e.g. Lego, K’nex,
Meccano)
Playing 1 : 1
Board games
Jigsaw
Ball games
Riding a bicycle
Balancing games
Comments: ____________________________________________________________
______________________________________________________________________
Functional Skills –Productivity/School Work
Please circle any of the following that your child has DIFFICULTY with:
Speed of writing
Letter formation
Spelling
Tidiness of writing
Holding Pencil
Learning
Using scissors
Reading
Sequencing
Maths
Memory
P.E.
Drawing
Colouring
Attention/Concentration
Comments: ______________________________________________________________
________________________________________________________________________
4
Ref: MS1a (13).doc
Please use this space to tell us more about your concerns or give any further
information regarding your child’s co-ordination skills:
We look at this form to help decide if your child needs to be seen by our service(s).
If you are sent an appointment we ask that you ring to confirm your attendance.
If we do not hear from you we will assume that you do not wish your child to be seen and he/she
will be discharged from the service and the referrer notified.
This form was completed by:
____________________________________________ on _____________________(Date)
Relationship to child: ______________________________________________________
Thank you for taking time to complete this form.
Please return it to:
Occupational Therapy Service / Physiotherapy Service
Woodview Child Development Centre
Crow Wood Lane
Widnes
Cheshire
WA8 3LZ
5
Ref: MS1a (13).doc