SYDNEY DEVELOPMENTAL CLINIC
PARENT QUESTIONNAIRE2005
Dear Parent/Guardian
Please complete this form to the best of your ability. Feel free to add comments if you wish. Bring
the completed form with you to the appointment.
Date form filled in:
______ /_______/________
1. Child’s name: ______________________________________________________________
2. Child’s Date of Birth:
______ /_______/________
3. Please circle:
Male / Female
4. Child’s address: _____________________________________________________________
______________________________________________________POST CODE: ___________
5. Your name: ________________________________________________________________
6. Your relationship to the child: __________________________________________________
7. What are your concerns about your child?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
8. Has a diagnosis been made? If ‘Yes’, please list all diagnoses:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
9. What are your child’s strong points?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
10. Is your child on any regular medicines? If ‘Yes’, please list all below:
______________________
Dosage______________
______________________
Dosage______________
______________________
Dosage______________
11. Are they effective? If ‘Yes’, how do they help:
________________________________________________________________________________
12. Do they have any side effects? If ‘Yes’, please describe:
________________________________________________________________________________
13. What school does your child attend? ___________________________
14. What grade is he/she in?
Grade: _______________
© SDC, 2005
Continued over /2
2
Compared to other children of the same age, how would you rate your child on the following
behaviours (0-25) now or within the past six months? Please circle the appropriate response.
0 = Not at all
1 = Just a little/sometimes
2 = Pretty much/often
3 = Very much/ often
1)
Actively defies or refuses to comply with adults’ requests or rules.
0
1
2
3
2)
Argues with you, his teacher and other adults.
0
1
2
3
3)
Avoids, dislikes or is reluctant to engage in tasks that require prolonged concentration (e.g.
schoolwork or homework).
0
1
2
3
4)
Blames others for his/her own mistakes or misbehaviour.
0
1
2
3
5)
Blurts out answers to questions before they have been completed.
0
1
2
3
6)
Deliberately annoys people.
0
1
2
3
7)
Does not seem to listen when spoken to directly.
0
1
2
3
8)
Fails to give close attention to details in schoolwork, work or other activities.
0
1
2
3
9)
Fidgets with hands or feet or squirms in seat.
0
1
2
3
10)
Has difficulty awaiting his/her turn.
0
1
2
3
11)
Has difficulty keeping attention on work or games.
0
1
2
3
12)
Has difficulty organising tasks and activities.
0
1
2
3
13)
Has difficulty playing or engaging in leisure activities quietly.
0
1
2
3
14)
Has trouble following through on instructions and fails to finish school work, chores or
duties.
0
1
2
3
15)
Interrupts or intrudes on others (e.g. butts into conversations or games).
0
1
2
3
16)
Is “on the go” or acts as if “driven by a motor”.
0
1
2
3
17)
Is angry and resentful.
0
1
2
3
18)
Is easily distracted
0
1
2
3
19)
Is forgetful in daily activities.
0
1
2
3
20)
Is touchy or easily annoyed by others.
0
1
2
3
21)
Leaves seat in classroom or other situations in which remaining seated is expected.
0
1
2
3
22)
Loses his/her temper or throws tantrums when he/she does not get his/her own way.
0
1
2
3
23)
Loses things necessary for tasks or activities at home or school (e.g. pencils, toys or tools).
0
1
2
3
24)
Often talks excessively.
0
1
2
3
25)
Runs about or climbs excessively in situations where it is inappropriate.
0
1
2
3
© SDC, 2005