General Knowledge

Dear Parent/Caregiver,

This questionnaire will help us learn about your child's communication skills.

Please Complete the questionnaire.

Tick all behaviours that your child has previously exhibited or currently exhibits.

Please note, that we require your email to send you a copy of your answers.

We also require your name and phone number to be able to contact you to set a first appointment.

All info gathered in this form is private and only the therapist and parents would have access to it...

Thank you!

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Email *
Your Name: *
Your Phone Number: *
Your Relationship to child:
 *
Address: *
Child's First Name: *
Child's Last Name: *
Child's Date of Birth: *
Please use the name of the month instead of its number for less confusion.
e.g.: March 2nd 2019, or 2 March 2019
Child's Gender:
 *
Referred by: *
Reason of the consultation: *
Who is at the origin of the complaint? *
Child's Place of residence: *
Siblings: First Name, Age, Relationship
E.g. Sam, 12, Brother
Lilly, 9, Sister
 *
Describe your child's relationship with his brothers and sisters or any other useful information to understand your child's development within the family (markable facts, does he play with his brothers and sisters, see them often, etc.) *
Family history:
School difficulties: *
Required
Speech-language difficulties: *
Required
Medical history:
Has the child received a diagnosis from a doctor or therapist? (if yes, specify in "Other")
 *
Wearing glasses/correcting glasses (if yes, specify in "Other") *
Allergies (if yes, specify in "Other") *
Hospitalizations (if yes, specify in "Other") *
Treatments and medications in progress (if yes, specify in "Other") *
Serous otitis media: *
Recurrent otitis media: *
Asthmatic bronchitis: *
Did he/she have an audiogram? *
Speech therapy sessions, current or previous? *
Required
Other therapeutic sessions, current or previous? *
Required
Pregnancy
Procreation *
Problems during Pregnancy (if yes, specify in "Other") *
Medications during Pregnancy (if yes, specify in "Other") *
Tobacco/Cannabis during pregnancy *
Term of pregnancy, in weeks (term = 41 weeks) *
Weight at birth *
Childbirth *
Psychomotor and language development
Laterality: *
Breastfeeding (if yes, specify up to what age in "Other") *
Required
Languages the child speaks *
Required
Sitting posture at what age? *
Walking on all four at what age? *
First steps at what age? *
First words at what age? *
First sentences at what age? *
Language or communication difficulties to report? *
Pacifier (if yes, specify up to what age in "Other") *
Thumb sucking (if yes, specify up to what age in "Other") *
Potty training (during the day): *
Potty training (during the night):
 *
Language level at school entrance *
Autonomy:
Can tie laces? *
Can ride a bike? *
Can get dressed alone? *
Can wash hands alone? *
Habits:
How much time does your child spend in front of a screen per day (TV/Computer/Game deck/Tablet...) *
Extracurricular activities (if yes, specify in "Other") *
Sleep
Waking up time during the weekdays *
Time
:
Sleeping time during the weekdays *
Time
:
Waking up time during the week-end *
Time
:
Sleeping time during week-end *
Time
:
Is bedtime schedule *
Does your child have troubles falling asleep in the evening? *
Does your child drool while sleeping? (Spots on the pillow) *
Does your child snore at night? *
Does your child still drink milk from the bottle? (If yes, specify how many times per day and when in "Other") *
Character/Behavior:
Get discouraged quickly *
Anxious *
Nervous *
Agitated *
Calm *
Shy *
Shows self confidence *
Fast *
Slow *
Bites nails *
Twitch or other tics (if yes, specify in "Other") *
Sociable *
Helpful *
Affectionate *
Emotional *
Sensitive *
Jealous *
Others
School/daycare:
Name of the school/daycare: *
Number of years in this school/daycare: *
Languages taught at school/daycare: *
Required
Current class: *
Teacher (Name, Subject) *
Previous schools/daycares: *
Feelings of the child during current class: *
Academic results for current class: *
Teachers' complaints about his academic results: *
Feelings of the child during his previous classes: *
Academic results for his previous classes: *
Teachers' complaints about his previous academic results: *
Duration per day, needed to do homework at home:
Any additional info you want to add: *
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