PARENT QUESTIONNAIRE
Child’s Name:
Birthdate:
Parent(s) Names:
Address:
Home Telephone:
Email:
Parent(s) Employer(s):
Allergies:
Food
Animals
Does your child have any medical conditions we should be aware of?
What are you most proud of about your child?
What worries or concerns you about your child?
What is your child’s favorite play to play?
What roles does your child frequently engage in during play?
What activities do you most like to share with your child?
Is there a favorite friend or relative your child might talk about, real or imaginary?
What does your child do when he/she is upset and how is he/she best comforted?
Does your child have fears or worries that we should be aware of?
Is there something that your child has just learned that is important to him/her?
What do you enjoy most aobut your child?
How does your child usually react to new situations?
Has your child been separated from either parent for a long period? If so, how did your child react?
What things repeatedly cause conflict between parents and children in your family?
Is your child happy playing alone?
Your child’s favorite activities:
List the ages and genders of your child’s most frequent playmates:
Eating
As a rule, is your child’s appetite excellent, good, fair or poor?
Does your child eat alone or with the family?
List your child’s favorite foods.
Any foods that your child especially dislikes?
Sleeping
Approximate time your child goes to bed
Approximate time your child wakes in morning
Your child’s attitude at bedtime
Usual activities before your child goes to bed
Elimination
At what stage is toilet training (no interest, interested, some attempts)?
If training has started,
Bowel control – response to training?
Bladder control – response to training?
Are there words your child uses when stating the need for elimination?
Family Section
What activities does your family enjoy most?
What holidays do you celebrate?
Are there any special skills in your family – i.e. playing musical instruments, speaking a foreign language?