Parent Questionnaire

What school level is your child in? *

Preschool/Daycare/KindergartenPrimary School/High School

Your Child

Child's Full Name *

Date of Birth *

Today's Date

Date of CDN Appointment

Preschool/Daycare/Kindergarten

Current School

How many days a week do they attend?

How long has your child been there?

What grade is your child in currently?

Parent/Guardian 1 Name *

Parent/Guardian 1 Occupation

Parent/Guardian 2 Name

Parent/Guardian 2 Occupation

If separated please indicate (✓)
If you are separated, we will need to discuss correspondence arrangements with you.

Siblings

Name

Age

Relationship

Live in the house

What does your child enjoy, do well, and what do you like about them?

What concerns you, and what don't you understand about your child?

What would you like from us?

Your child's health

Any concerns about your child's health currently?

YesNo

Any concerns about the pregnancy?

YesNo

Any concerns about the birth and postnatal period?

YesNo

Any accidents / injuries / serious illnesses in the past?

YesNo

Has your child's hearing been checked?

YesNo

If it has been checked, was it normal?

Has your child's vision been checked?

YesNo

If it has been checked, was it normal?

Is your child fully immunised?

YesNo

Are there any other important medical issues?

YesNo

What was the birth weight?

If premature, how many weeks?

As your child was growing up, were you concerned about

The first year? (eg. hard to settle, poor weight gain)?

YesNo

Early motor development (sitting, walking, running)?

YesNo

Early language (talking and understanding)?

YesNo

Early social development (eye contact, play, friends)?

YesNo

Early learning (e.g. colours, shapes, drawing)?

YesNo

Any other major concerns during early childhood?

YesNo

The Family

Does anybody in the family (siblings, parents, grandparents, aunts, etc) have problems similar to, or the same as your child?

YesNo

Does anybody in the family (siblings, parents, grandparents, aunts, etc) have different problems, of a developmental, learning, behavioural, emotional or psychiatric nature?

YesNo

For anything identified above, is there anything in particular that you would like to discuss?

Who have you consulted for your child's difficulties?

Please list any past/present Health and Education Services including Medical supports (e.g. GP, other paediatricians, child psychiatrists); Allied health (e.g. Occupational Therapist, Physiotherapist, Speech Pathologist, Psychologist, Social Worker/Counsellor); Educational professionals (e.g. Guidance Officer, Learning Support Teacher, Home Tutor); and Other supports (e.g. Naturopath).

Please remember to bring a copy of all written reports to your appointment.

Health / Education Services

Currently

In the past

Who

Who is your GP?

For any professionals identified, please summarise their involvement.

When you come to see us

Sensitive Information

Is there any sensitive information that you would prefer to not talk about in front of your child?

YesNo

If yes, we can discuss these issues while the child waits outside. You may wish to bring a book or something for them to do while they wait. If they will need supervision, please bring somebody along to supervise them.

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