Occupational Therapy Quick Questionnaire

Hello :) 

This is a quick occupational therapy questionnaire. Depending on results, a formal evaluation may be necessary to learn more. Thank you for taking the time to fill this out! 

***Please use this guide to understand milestones for these self-care tasks.
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Please provide your name. *
Please provide your email. *
Please provide your phone number for follow up. *
Will you be using the Step Up Scholarship - Unique Abilities? *
What city do you live in OR city where your child will receive treatment? *
How old is your child? *
Self-Care
Does your child:

Dress themselves?

 *

Have difficulty tying their shoes?

 *

Avoid having their hair/nails cut, teeth brushed, or face washed?

 *
Eating
Does your child:

Have trouble using a utensil? 

(If yes, which?)

 *
Required

Eat less than 10 types of foods?

 *

Gag easily when eating or smelling certain food textures?

 *
Sensory Processing
Tell me about how your child interacts with their surroundings
Does your child:

Constantly move, which interferes with daily activities?

 *

Seem clumsy, bump into things, unaware of objects or people?

 *

Have more than 3 meltdowns a day? (more info) 

 *

Seem quick to anger

 *
School Tasks
Tell me how your child completed school activities.
Does your child:

Have difficulty holding a writing utensil (pencil, marker, crayon, etc.)? 

***Please use this guide to understand milestones for this school task.

 *

Have difficulty using scissors?

***Please use this guide to understand milestones for this school task.

 *

Have difficulty with completing school tasks? (Circle time, working in centers, transitioning between tasks, etc.)

 *
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