INITIAL ASSESSMENT QUESTIONNAIRE WITH SCORING – PARENTS
Instructions
Tick the option that best describes the child’s behavior.
Scoring:
• ☐ 0 = Never
• ☐ 1 = Rarely
• ☐ 2 = Sometimes
• ☐ 3 = Frequently
• ☐ 4 = Always
I. General Information
• Child’s name: __________________________
• Age: __________
• Parent/guardian: __________________________
II. Psychological (Cognitive) Development
Item
0 1 2 3 4
Responds to name
☐☐☐☐☐
Maintains eye contact
☐☐☐☐☐
Recognizes familiar people
☐☐☐☐☐
Understands simple instructions ☐ ☐ ☐ ☐ ☐
Focuses on an activity
☐☐☐☐☐
Plays appropriately with objects ☐ ☐ ☐ ☐ ☐
Sorts objects
☐☐☐☐☐
Completes simple tasks
☐☐☐☐☐
Domain II score: ______ / 32
III. Language and Communication
Item
0 1 2 3 4
Makes sounds/vocalizations ☐ ☐ ☐ ☐ ☐
Says words
☐☐☐☐☐
Forms sentences
☐☐☐☐☐
Understands language
☐☐☐☐☐
Initiates communication
☐☐☐☐☐
Uses gestures
☐☐☐☐☐
Responds to questions
☐☐☐☐☐
Clear speech
☐☐☐☐☐
Domain III score: ______ / 32
IV. Behavior and Socialization
Item
0 1 2 3 4
Interacts with children
☐☐☐☐☐
Interacts with adults
☐☐☐☐☐
Participates in play
☐☐☐☐☐
Accepts changes
☐☐☐☐☐
Waits for their turn
☐☐☐☐☐
Expresses emotions appropriately ☐ ☐ ☐ ☐ ☐
Reverse-scored items (problem behaviors)
Item
0 1 2 3 4
Frequent tantrums ☐ ☐ ☐ ☐ ☐
Repetitive behaviors ☐ ☐ ☐ ☐ ☐
👉 For these items the scoring is reversed:
0→4, 1→3, 2→2, 3→1, 4→0
Domain IV score: ______ / 32
V. Personal Autonomy
Item
0 1 2 3 4
Eats independently
☐☐☐☐☐
Dresses self
☐☐☐☐☐
Personal hygiene
☐☐☐☐☐
Uses toilet
☐☐☐☐☐
Moves independently
☐☐☐☐☐
Requires supervision (reversed) ☐ ☐ ☐ ☐ ☐
👉 Reverse-scored item
Domain V score: ______ / 24
VI. Motor Development
Item
0 1 2 3 4
Balance
☐☐☐☐☐
Coordination
☐☐☐☐☐
Fine motor skills
☐☐☐☐☐
Item
0 1 2 3 4
Object manipulation ☐ ☐ ☐ ☐ ☐
Physical activity
☐☐☐☐☐
Domain VI score: ______ / 20
VII. Sensory Sensitivity
Item
0 1 2 3 4
Sensitive to noise
☐☐☐☐☐
Sensitive to touch
☐☐☐☐☐
Seeks excessive stimulation ☐ ☐ ☐ ☐ ☐
Adapts to environment
☐☐☐☐☐
Tolerates changes
☐☐☐☐☐
👉 First 3 items are reverse-scored
Domain VII score: ______ / 20
VIII. TOTAL SCORE
Total: ______ / 160
IX. INTERPRETATION
Total score:
• 120 – 160 → typical development / mild difficulties
• 80 – 119 → moderate delay
• < 80 → significant delay
Interpretation by domains
• 75–100% → good level
• 50–74% → moderate difficulties
• < 50% → severe difficulties
X. Parent Comments
Declaration
☐ I declare that the information provided is accurate
Date: ___________
Signature: __________________________
