Monroe County Schools RtI
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Monroe County Schools RtI Form 9 RtI Parent Questionnaire Personal Information Child’s Name ___________________________________ Date_______________________________ DOB _______________________ Gender______________ Address ________________________________________________________________________________ ________________________________________________________________________________ Phone Number ________________________________ Name of Person Completing Questionnaire _____________________________________________ Relationship to Child ______________________________________ Who does child live with? ______________________________________________________________ Mother’s Name____________________________________Occupation________________________ Father’s Name ____________________________________Occupation________________________ Does your child have siblings? __________ yes ____________no If yes, How many? (list gender(s) and age(s) _____________________________________________________________________________________ ____________________________________________________________________________________ Birth History Were there any complications during pregnancy? (If yes, Explain) _________________________ _______________________________________________________________________________________ ______________________________________________________________________________________ Was Child born prematurely? Yes ___________ No___________ If yes, how many weeks or months? _____________________________________________________ Were there any problems during labor or after birth? Yes ______________ No_______________ If yes, explain. _________________________________________________________________________ ______________________________________________________________________________________ Response to Instruction Updated August 2011 Monroe County Schools RtI Form 9 Developmental History How old was your child when he/she talked? _____________________ How old was your child when he/she crawled? ____________ walked? ____________________ At what age was your child’s potty trained? _____________________ Did your child have any problems sleeping through the night? _________________________ At what age did they sleep through the night?________________________________ Does your child have hearing or vision problems? __________________________________ Did your child have ear infections as an infant or toddler? _______________ How often? __________________________________________________________________________________ Family History Do any family members have a history of learning problems? Be specific.________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do any family members have any medical problems? Be specific. _______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ About Your Child What are some of child’s interests? ______________________________________________________ _______________________________________________________________________________________ Likes___________________________________________________________________________________ Dislikes________________________________________________________________________________ Does your child have any allergies?________________ Please specify.________________________ _______________________________________________________________________________________ Does your child take any medications? Yes _____________________ No______________________ If yes, please explain. __________________________________________________________________ Response to Instruction Updated August 2011 Monroe County Schools RtI Form 9 Has your child ever received any special services? Yes_____________ No __________________ _______________________________________________________________________________________ Did your child attend Pre-school? Yes__________ No_____________ If yes, Where? ________________________________________________________________________ How was his/her preschool experience? _________________________________________________ ______________________________________________________________________________________ Socialization Attention _________Plays well with others ________Easily Distracted _________Included by peers in activities ________Makes eye contact _________Works well in a group ________Forgets Directions _________Prefers to play alone Behavior Speech ________Excitable _______Speaks in clear easily understood phrase or sentences ________Very Active _______Expresses wants and needs _______Needs instructions repeated ________Does not Follow Requests ________Unable to accept limits ________Disinterested in people ________Interactive well with peers Self Help ________Needs assistance with toileting ________Needs assistance with feeding ________Needs assistant with dressing ________Hits ________Kicks ________Bites ________Unaware of danger ________Quiet or Withdrawn ________Fearful Comments:_______________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Response to Instruction Updated August 2011 Monroe County Schools Response to Instruction RtI Form 9 Updated August 2011
