Title: Parent Questionnaire
Author: Project ACCESS
Last saved by: Neal-Fox, Tina J

This form is not copyrighted. Educators have permission to reproduce and use this form for educational, non-profit use.

Parent Questionnaire
Student’s name: | D.O.B.:
School district: | Sex:
Person completing form: | Date:
Address | Phone:
City/state | Zip
Mother: |
Father: |
Address (if different than person completing the form) |
| Phone:
City/state_ | Zip

Names of Siblings* | Sex | Age | Grade | Living in Home?
*If the child is a twin, please note by marking an asterisk by the name of the twin. 

Thank you for completing this questionnaire!
Thank you for taking time to answer these questions. This may seem like a lot of questions, and you may not remember exact dates some things happened. Just do your best. Your answers will help the school determine how best to teach your child. Thanks again for your time. 
1.	
Were academic difficulties or special problems experienced by brothers or sisters? ❑ Yes ❑ No If yes, explain. 

2.	Are there other adults or relatives in the home? Give relationship: 

3.	What language is spoken in the home? 

4.	In your own words, describe your child’s problem. 

5.	What is your greatest concern about your child? 

6.	Child’s birth was: ❑ normal ❑ premature ❑ overdue 
7.	Delivery was: ❑ normal ❑ instrument ❑ cesarean 

8.	Weight at birth was: ___ lbs. ___ oz. 

9.	Health of child at birth: 

10.	Mother’s health during pregnancy was: ❑ good ❑ fair ❑ poor 

11.	History of birth injury: 

12.	Describe your child as a baby (e.g., a good baby, cranky, colicky, slept a lot, easy to hold, stiff).

13.	Has your child had difficulties since birth or soon after? ❑ Yes   ❑ No If yes, please describe:

14.	Did he or she stop developing at some point in time? ❑ Yes ❑ No 
15.	If yes to question 14, what do you think might be the cause? 

16.	Is the child on any medication? ❑ Yes ❑ No 

17.	If yes to question 16, please complete: 
Types of Medication | Reason Prescribed | Taken How Often? | Dosage | How Long on Medication?
18.	Has your child suffered any head injuries? ❑ Yes ❑ No If yes, give details: 

19.	Have you ever been concerned about your child’s behavior or speech and taken him or her to a doctor or other specialist for advice? ❑ Yes ❑ No If yes, please explain: 

20.	Has a doctor or other specialist ever told you your child has a behavior or speech problem? 
❑ Yes ❑ No If yes, please explain: 

21.	Have you ever been told by a doctor or other specialist that your child was hearing-impaired or deaf? ❑ Yes ❑ No 
22.	Has your child ever been hospitalized? ❑ Yes ❑ No If yes, explain: 

23.	Has your child had any of the following? 
❑ Frequent ear infections 		❑ Allergies 
❑ Frequent sinus infections 	❑ Seizures 

24.	Crawled for the first time: ❑ at about the usual age OR ___ years ___ months 
25.	Walked alone: ❑ at about the usual age OR ___ years ___ months 
26.	Does your child have an unusual gait or walk pattern (e.g., toe-walker)? ❑ Yes   ❑ No 
If yes, please describe: 

27.	Does your child show any of the following behaviors? 
❑ Biting nails 				❑ Biting, hitting, or pinching self 
❑ Twitching 				❑ Spinning 
❑ Unusual hand/finger movements 	❑ Head banging 
❑ Rocking 				❑ Fascination with moving or spinning objects 

28.	Does your child have any unusual reactions to any of the following? If yes, please explain: 
❑ Sound 
❑ Smells 
❑ Things he or she sees 
❑ Touch 
❑ Taste _

29.	Does your child have any other unusual reactions? 

30.	
How does your child handle transportation (e.g., rides easily, resistive)? 

31.	To what degree is your child sensitive to pain? 

32.	How does your child respond to affection (e.g., hugging, holding hands, patting)? 

33.	Does your child give affection? ❑ Yes   ❑ No If yes, to whom? 

34.	How does your child react to changes in the way things happen (e.g., changes in routine, different foods, different routes, new people)? 

35.	Does your child have temper tantrums? ❑ Yes   ❑ No 
If yes, how often? 
How long are they? _
Describe the intensity: 

36.	Is your child destructive to self, others, or property? ❑ Yes ❑ No 
37.	Bladder control was achieved: ❑ at about the usual age OR ___ years ___ months 

38.	Bowel control was achieved: ❑ at about the usual age OR ___ years ___ months 

39.	Does your child have any unusual toileting behaviors? ❑ Yes ❑ No If yes, please describe: 

40.	Does your child make eye contact with people in the usual way? ❑ Yes ❑ No If no, explain: 

41.	Describe your child’s interaction with peers: 

42.	Do peers enjoy your child or merely tolerate him or her? 

43.	Describe your child’s interaction with family: 

44.	Describe your child’s interaction with adults: 

45.	Does your child get along with brothers and sisters? ❑ Yes ❑ No If no, please explain: 

46.	When left to play by him or herself, how does your child spend his or her time (i.e., unstructured situations)? 

47.	Does your child play with toys? ❑ Yes ❑ No If yes, what does he or she do with them? If no, what does he or she play with? 

48.	
Does your child display unusual fascination with special objects, machinery, computers, etc.? 
❑ Yes ❑ No If yes, describe: 

49.	Can your child be left with others (e.g., sitter, relatives)? Describe: 

50.	Is it difficult taking your child out in public places (e.g., church, shopping, movies, friends’ homes)? Explain: 

51.	Describe your child’s behavior activity and changes which might occur in various situations (e.g., changes in order of environment, moving furniture, someone visiting) and give examples: 

52.	Does your child seem to notice other people and/or different places? Explain: 

53.	Does your child talk? ❑ Yes ❑ No If yes, when were his or her first words spoken? 

54.	Is the speech unusual in any way (e.g., milestones, high pitched, off the subject, parrot-like, says some things over and over)? ❑ Yes ❑ No If yes, please explain: 

55.	How long does your child pay attention? 

56.	Does he or she show independence or depend too much on others? Discuss: 

57.	How does your child go about getting or doing what he or she wants (e.g., diplomatic maneuver, take forcibly, buy favors, tease, acting out)? Discuss: 

58.	Does your child exhibit any outstanding qualities or talents (e.g., early reading, mathematic skills, outstanding memory, mechanical abilities, music, art, balance)? Explain: 

59.	Does your child imitate others’ speech, repeating or parroting back the same words? 
❑ Yes ❑ No 
60.	If your child does not have speech, describe how he or she lets you know what he or she wants (e.g., communication boards, sign language, gestures): 

61.	Does your child ask questions? ❑ Yes ❑ No 
62.	Does your child respond to questions? ❑ Yes ❑ No 
63.	Can nonfamily members understand what your child wants? ❑ Yes ❑ No 
64.	Does your child cry or laugh for little or no apparent reason? ❑ Yes ❑ No 
65.	Does your child display unusual fears? ❑ Yes ❑ No If so, describe: 

66.	How does your child respond to dangerous situations (e.g., oncoming traffic, electric fan)? 

67.	
In what activities or areas is your child most successful? 

68.	What have you done to assist, handle, or cope with your child’s problems? 

69.	What disciplinary measures are used at home? 

70.	What methods have you found most effective? 

71.	Who administers them? 

72.	Is the discipline consistent? 

73.	When you are happiest with your child, what is he or she doing? 

74.	In what activities or areas is your child least successful? 

75.	Describe your child’s sleep patterns (e.g., sleeps at regular times, up all night): 

76.	
Is there any other information that you think is pertinent which might be helpful? 

77.	What is your view of the future for your child? What do you want to see in the areas of education, vocation, living arrangements, etc.? Please discuss: