Test

Name of Child:

Date of Birth:

Name of person filling questionnaire:

Relationship to child:

Preffered contact number:

Home address:

Email address:

Date questionnaire completed:

Birth weight:

Pregnancy -

If premature - (born at __ weeks)?

Please describe any important illnesses, injuries or surgeries:

Current medical diagnoses / conditions (ADHD, Autism, CP etc)

Current medication prescribed:

Developmental milestones. Approximate age at which your child - Raised head:

Developmental milestones. Approximate age at which your child - Rolled:

Developmental milestones. Approximate age at which your child - Sat alone:

Developmental milestones. Approximate age at which your child - Crawled on hands and knees:

Developmental milestones. Approximate age at which your child - Pulled to stand:

Developmental milestones. Approximate age at which your child - Stood alone:

Developmental milestones. Approximate age at which your child - Walked:

Your general impression of your child's gross motor skills (running, jumping, ball play):

Your general impression of your child's fine motor skills (manipulation of objects with hands):

Your general impression of your child's handwriting and colouring skills:

Favourite indoor play:

Favourite outdoor play:

What are your child's strengths:

Does your child tire easily during activities:

Does your child appear fearful of movement or heights

Multiple Choice