PARENT QUESTIONNAIRE Dear Parents, Please help us get to know your child by filling out this form. All the information will be confidential. We will use what you tell us as we begin to get to know your child and plan ways to meet his/her needs and to help him/her develop. Please return it to school as soon as possible. Thanks so much!Child's NameChild's NicknameParents’ NamesDate MM slash DD slash YYYY Child’s TeacherDoes your child live with? Both Parents One Parent Other adults Please SpecifyPlease list the names and ages of others who live in your home. (This will help me write names correctly on pictures your child draws about his/her family.)Pets (Name & type of animal)Father’s OccupationMother's OccupationDoes your child have a room of his own? Yes No If not, with whom does he/she share a room?What are your child’s favourite play activities and interests?Does child use special words to go to the bathroom?Child’s favorite TV programsHours per day spent watching TVDoes your child usually play Alone? With a friend? With a few friend? with younger children? with older children? with children the same age? Does child have decided fears? If so, what?What responsibilities does your child have at home?What is your biggest discipline problem?How do you discipline your child?What is your child’s favorite story or type of story or book?Did your child have a premature or difficult birth that may indicate cognitive delays?Is English your child’s first language? If not, what is?Is English the primary language spoken in the home? If not, what is?Does your child speak any English? Understand English?How does your child feel about coming to school?What do you hope your child will learn this year?Please make comments about anything else you think I need to know about your childIt is our goal to encourage a sense of belongingness, promote an appreciation of others and enrich children’s experiences by integrating into our curriculum activities and information that reflect our individual children’s background. One way we can do this is by learning about each child’s family background, celebrated holidays, and traditions. Please take a few minutes to share with us your special family days or activities and how they are carried out in your home.What languages other than English are spoken by family members around your child?Does your child have any physical or learning disabilities? If so, please describeAre there any family members with disabilities that may directly impact your child’s daily life (for example, a deaf grandparent, wheelchair bound parent, etc.)?What information about your family’s background and culture would you like to share with us?What are the holidays, special days, or traditions your family partakes in?Are there any special foods, songs, items or symbols you include in your celebration of special family times?Does your child have any dietary restrictions due to allergies, intolerances, family or religious preferences? If yes, what is restricted?Are there any activities from your family’s culture or traditions that you would like to share with your child’s classroom?What is the most important thing I should know about your child?What are their strengths?What are the areas of weakness? What would you love for your child to get better at?My child learns best when the teacher is….My child does not work well with…What is the best way to motivate your child?What are you looking forward to at YMIM?How would you like to be involved with your child’s education?What is your preferred method of communication (email, phone call, meeting, note…)Child’s date of birth: MM slash DD slash YYYY Is It a Boy Or a Girl? Boy Girl Email Date ASQ-3 completed by parent/caregiver: MM slash DD slash YYYY Date of review with health professional: MM slash DD slash YYYY Child’s home addressTownPostcodePerson completing the questionnaireRelationship to child:Home tel:Mobile noAll children develop at different rates and in different ways. Please do not worry if your child is not doing all or any of the activities mentioned in the questionnaire. It is not a test. The activities are simply one way of understanding how your child is progressing Possible answers: Yes = your child does this activity (or has done it and has now progressed, e.g., crawling, but is now walking) Sometimes = your child is just beginning to do this activity (but does not do it regularly) Not Yet = your child has not yet started doing this Please leave blank any activities your child has not been able to try with youImportant Points to Remember: Try each activity with your child before marking a response. Make completing this questionnaire a game that is fun for you and your child. Make sure your child is not tired or hungry. Please bring this questionnaire with you to your child’s health and development review.Additional NotesCommunicationIf you point to a picture of a ball (cat, cup, hat, etc.) and ask your child, “What is this?” does your child correctly name at least one picture? Yes Sometimes Not Yet Without giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions? 1. “Put the toy on the table.” 2. “Close the door.” 3.“Bring me a towel.” 4. “Find your coat.” 5.“Take my hand.” 6. “Get your book.” Yes Sometimes Not Yet When you ask your child to point to her nose, eyes, hair, feet, ears, etc., does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark “sometimes” if he/she correctly points to at least three different body parts.) Yes Sometimes Not Yet Does your child make sentences that are three or four words long? Yes Sometimes Not Yet Please give an example of your child’s word combinations:Without giving your child help by pointing or using gestures, ask him to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly? Yes Sometimes Not Yet When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, “barking,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?” Yes Sometimes Not Yet Communication TotalGROSS MOTORDoes your child run fairly well, stopping herself without bumping into things or falling over? Yes Sometimes Not Yet Does your child walk either up or down at least two steps by himself? He may hold onto the handrail or wall. (You can look for this in a shop, in a playground, or at home.) Yes Sometimes Not Yet Without holding onto anything for support, does your child kick a ball by swinging his leg forward? Yes Sometimes Not Yet Does your child jump with both feet leaving the floor at the same time? Yes Sometimes Not Yet Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) He/She may hold onto the handrail or wall. Yes Sometimes Not Yet Does your child stand on one foot for about 1 second without holding on to anything? Yes Sometimes Not Yet GROSS MOTOR TOTALFINE MOTORDoes your child use a turning motion with her hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars? Yes Sometimes Not Yet After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask him to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a vertical direction? Yes Sometimes Not Yet Can your child string small items such as pasta or beads onto a string or shoelace? (Carefully watch your child’s use of beads and string for safety reasons.) Yes Sometimes Not Yet After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. Do not let your child trace your line. Does your child copy you by drawing a single line in a horizontal direction? Yes Sometimes Not Yet After your child watches you draw a single circle, ask him to make a circle like yours. Do not let him trace your circle. Does your child copy you by drawing a circle? Yes Sometimes Not Yet Does your child turn pages in a book, one page at a time? Yes Sometimes Not Yet FINE MOTOR TOTALPROBLEM SOLVINGWhen looking in the mirror, ask, “Where is ______?” (Use your child’s name.) Does your child point to her image in the mirror? Yes Sometimes Not Yet If your child wants something he cannot reach, does he find a chair or box to stand on to reach it (for example, to reach a toy on a table or worktop or to “help” you in the kitchen)? Yes Sometimes Not Yet While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use cotton reels, small boxes, or other toys.) Yes Sometimes Not Yet When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”) Yes Sometimes Not Yet Please write your child’s response here:When you say, “Say, ‘seven three,’” does your child repeat just the two numbers in the same order? Do not repeat the numbers. If necessary, try another pair of numbers and say, “Say, ‘eight two.’” Your child must repeat just one series of two numbers for you to answer “yes” to this question. Yes Sometimes Not Yet After your child draws a “picture,” even a simple scribble, does she tell you what she drew? (You may say, “Tell me about your picture,” or ask, “What is this?” to prompt her.) Yes Sometimes Not Yet PROBLEM SOLVING TOTALPERSONAL-SOCIALIf you do any of the following gestures, does your child copy at least one of them? 1. Open and close your mouth 2.Blink your eyes. 3. Pull on your earlobe. 4. Pat your cheek Yes Sometimes Not Yet Does your child use a knife/fork and spoon to feed himself? Yes Sometimes Not Yet Does your child push a little truck, doll’s buggy, or other toy on wheels, steering around objects and backing out of corners if she cannot turn? Yes Sometimes Not Yet Does your child put on a coat, jacket, or shirt by himself? Yes Sometimes Not Yet After you put on loose-fitting trousers around her feet, does your child pull them completely up to her waist? Yes Sometimes Not Yet When your child is looking in a mirror and you ask, “Who is in the mirror?” does he say either “me” or his own name? Yes Sometimes Not Yet PERSONAL-SOCIAL TOTALOVERALL Parents and providers may use the space below for additional comments.Do you think your child hears well? If no, explain Yes No Do you think your child talks like other toddlers her age? If no, explain: Yes No Can you understand most of what your child says? If no, explain: Yes No Can other people understand most of what your child says? If no, explain: Yes No Do you think your child walks, runs, and climbs like other toddlers his age? If no, explain: Yes No Does either parent have a family history of childhood deafness or hearing problems? If yes, explain: Yes No Do you have concerns about your child’s eyesight? If yes, explain: Yes No Has your child had any medical or health-related problems in the last few months? If yes, explain: Yes No Do you have any concerns about your child’s behaviour? If yes, explain: Yes No Does anything about your child worry you? If yes, explain: Yes No Δ
