CHILD DEVELOPMENT QUESTIONNAIRE
Today’s date:
First name:
First Step Diagnostician:
CHILD DETAILS:
Last name:
Birth date:
Gender:  M  F
Birth weight:
Birth week:
Address:
First name:
Age:
Email:
Skype name:
First name:
Age:
Email:
Skype name:
Age:
Home phone:
MOTHER'S DETAILS
last name:
Occupation:
Cell Phone:
FATHER’S DETAILS
last name:
Cell Phone:
SIBLINGS:
name:
Age:
name:
Age:
name:
Age:
Occupation:
Corrected age
(preemies):
What is the reason for contact with “First Step”?
Referred to “First Step” by:
In what structure is the child?
Information on child development from pregnancy to age 2 years:
Pregnancy: normal yes / no – Explain:
Labor: normal / C-section / vacuum / tongs. Explain:
Apgar score post labor
State of fetus in labor: breech / normal / width
Illnesses and hospitalizations:
Has the child been ill? Yes/No - Explain
Has the child been
at age:
Reason:
hospitalized? No / Yes
Has the child undergone other treatments? No / Yes – Explain:
Treatment:
Name of provider:
Phone number:
Treatment:
Name of provider:
Phone number:
Has the child been diagnosed by another professional? No / Yes:
* In the case of a treatment, please attach relevant documents.
Additional activities or classes: No / Yes:
Developmental background up to the age of 2:
Did the toddler progress through all the stages of motor development? (Lying on the stomach, lifted
the head, rolled, belly crawled, rose on hands and knees, sat down and stood up independently)
Was the child’s motor development slow, normal or quick?
Were there any developmental interventions during the first two years (physical therapy, speech
therapy, occupational therapy, orthopedist etc?)
*In the event that there were please attach all related materials.
How would you describe the child as a baby: quiet, restless, nervous, cried frequently, rarely cried?
At what age did the child begin preschool or nursery school?
Describe the child’s sleeping habits at a baby: in arms, in the car, required a pacifier or other object
woke up often.
Information on child development from pregnancy to age 2 years:
Pregnancy: normal yes / no – Explain:
Labor: normal / C-section / vacuum / tongs. Explain:
Apgar score post labor
State of fetus in labor: breech / normal / width
Illnesses and hospitalizations:
Has the child been ill? Yes/No - Explain
Has the child been
at age:
Reason:
hospitalized? No / Yes
Has the child undergone other treatments? No / Yes – Explain:
Treatment:
Name of provider:
Name of provider:
Treatment:
Name of provider:
Name of provider:
Has the child been diagnosed by another professional? No / Yes:
* In the case of a treatment, please attach relevant documents.
Additional activities or classes: No / Yes:
Developmental background up to the age of 2:
Did the toddler progress through all the stages of motor development? (Lying on the stomach, lifted
the head, rolled, belly crawled, rose on hands and knees, sat down and stood up independently)
Was the child’s motor development slow, normal or quick?
Were there any developmental interventions during the first two years (physical therapy, speech
therapy, occupational therapy, orthopedist etc?)
*In the event that there were please attach all related materials.
How would you describe the child as a baby: quiet, restless, nervous, cried frequently, rarely cried?
At what age did the child begin preschool or nursery school?
Describe the child’s sleeping habits at a baby: in arms, in the car, required a pacifier or other object
woke up often.
Were there special difficulties?
Developmental Background as child:
Does the child exhibit gross-motor skills? (Jumping, skipping, standing on one foot, rolling, running,
walking, other…)
Is there difficulty with fine-motor skills? (Eating, cutting, drawing, writing, threading, other…)
Has the child been diagnosed by another professional?
*In case he had treatment please attach related materials.
How would you assess the child’s general state of health?
Describe the child’s character and the special attributes of his personality.
Describe the family relations between the siblings and parents.
Is it easy for the child to create social contacts? Does he like being with friends?
What are your child’s preferred games?
Is there sensory sensitivity to touch or different textures? (Types of foods, sand, grass, avoids dirt,
other…)
Is there sensitivity to levels and intensity of sound?
Are there movement issues? (Falls a lot, avoids swinging, likes high intensity movement, other…)
Are there learning difficulties?
Have you encountered emotional difficulties? (Temper tantrums, low self-esteem, difficulty in
expressing emotions, cries a lot, overly irritated other…)
Please describe the child’s daily schedule by periods:
* Wakeup / how the child is roused
* Morning routine details
* Television
* Homework
* Friends
* Independent playtime
* Time with parents
* Meal details including snacks
* Bedtime routine details
* Falling asleep process
In order to help us learn more about your child’s current motor skill activity and levels, please answer
the following questions.
If you do not know the answers, encourage your child to move into these different positions and
observe the behavior and response:
Does the child lie on the stomach? Yes/No
In what position does the child sleep? On stomach/back/side/other
Does the child turn over to stomach from lying on the back? Yes/No
Does the child move independently from lying on the back to sitting? Yes/No
How? Through the side/front/with help/other
Does the child sit independently? Yes/No
Does he need help sitting down?
From lying on the stomach does the child stand on six?
Does the child crawl? Yes/No
Does the child go from sitting on the floor to standing up independently? Yes/No
Does the child go from sitting on a chair to standing up independently? Yes/No
Does the child need to hold on to something when standing? Yes/No
Does the child walk independently or does he/she need to hold on to something? Yes/No
Is there a tendency to full down when walking? Yes/No
Can the child sit down from standing? Yes/No
Thank you.