Parent Questionnaire on Child’s Development
Parents: Please take a moment to fill out this questionnaire on your child’s development.
Your cooperation is greatly appreciated.
1. What language is spoken in the home? English
 Other (specify)_______________
2. Has your child attended preschool/childcare before? Yes  No If yes, for how long?
6 months  2 years  more than 2 years
3. Were there any significant problems during pregnancy or directly following birth that
might influence your child’s development (ie. Premature birth, low birth weight, etc)?
4. Was your child more than 3 weeks premature?
5. How much did your child weigh?
6. Describe your child’s patterns with:
a. Feeding: ________________________________________________________
b. Sleeping: ________________________________________________________
c. Soothing: ________________________________________________________
d. Attachment: ______________________________________________________
e. Other medical concerns of early illness/injuries/accidents:
_________________________________________________________________
7. Describe your baby’s early personality: _______________________________________
_______________________________________________________________________
8. Do you see areas in which your child seems to be “stuck” or have gaps developmentally
/educationally/behaviorally/socially? If so, where? _____________________________
_______________________________________________________________________
9. What further development do you wish to see in your child?
________________________________________________________________________
________________________________________________________________________