Questionnaire for parent and child
This questionnaire will gather information about the learning needs and styles of the child along with background of the child.
SPECIAL NINJA LEARNING ACADEMY
Personal Information
This section requires details (Name, Age) of your child
Name of child
Child's Date of Birth
MM
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DD
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YYYY
Child's Grade
Name of School
Mother's Age
Father's Age
Birth History
This section requires information and detail about the child's birth history
1. Was the child a full term baby?
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2. What was the type of delivery?
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3. Was the child underweight at birth?
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4. Did the mother have an iron deficiency during pregnancy?
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5. Did the mother experience a high risk pregnancy?
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6. Did the child suffer from any neonatal infections or maladies?
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7. Was there a prolonged gap between the baby's birth and his/her first cry?
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Early Childhood
This section gathers information about your child's early behaviour in his/her initial years.
1. Did the child have any accidents or infections in his/her first year?
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2. Did your child skip or have delayed growth milestones? For ex: Did the child start crawling at the right age?
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Reading and Writing
These sections gather information on your child's reading and writing skills.
1. Does your child enjoy seeing pictures in books?
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2. Does your child have a particular toy/blanket/pair of clothing that he/she won't do away with?
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3. Does your child point out different colors?
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4. Does your child dance to any song/rhymes?
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5. Can your child pick up objects and stack them?
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6. Does your child indulge in pretend play?
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7. Does your child eat on his/her own?
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8. Is your child a fussy eater?
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9. Does your child have a bedtime routine?
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Mathematics and Numbers
This section gathers information about your child's Math and numerical skills
1. Does your child have a focussed play?
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2. Does your child share his/her toys?
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3. Does your child engage in shape sorting puzzles?
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4. Does your child show parts of the face like nose, eyes, ears?
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5. Does your child point out objects like fan, ac, tv?
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6. Is your child overtly attached to either of the 2 parents?
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Organisation, Memory and Sequencing
This section gathers information about some basic everyday activities of your child.
1. Is your child able to speak clearly and string together the right words while speaking?
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2. Does your child have trouble playing one game/ doing one activity beyond 10 minutes?
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3. Does your child tell his/her name?
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4. Does your child put random objects in his/her mouth?
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5. Does your enjoy being outdoors or indoors?
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6. Does your child struggle if the daily routine is disturbed?
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7. Is your child clumsy?
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8. Is your child afraid of escalators or stairs?
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Social Skills
This section gathers information about your child's social skills.
1. Does your child have one or no friends?
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2. Is your child very irritable in the company of other children?
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3. Does your child have stranger anxiety?
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4. Is your child happy upon waking up in the morning?
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5. Does your child like listening to stories?
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6. Does your child like seeing stories?
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