Parent - Child Assessment Questionnaire

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Is there any family history (both paternal and maternal extended families) of the following?
(if yes, please specify relationship, eg. maternal uncle, paternal niece)

(eg depression, anxiety, bi-polar, alcohol / drug abuse)
Please include the following: Health/Complications,Life events/major stressors, Post-natal depression, Birthweight, Pre-term/Fullterm, Delivery.
(e.g., feeding, sleeping, medical conditions, temperament/personality) (0-12 months)

Language
Age (in months) when your child (if you cannot remember, please indicate whether it was delayed or as expected/typical)

Motor
Age (in months) when your child (if you cannot remember, please indicate whether it was delayed or as expected/typical)

Is your child left or right handed?
Does your child have any difficulty with any of the following?
Has your child had any of the following

Has your child had any of the following health concerns (if yes, please describe)?

Are there relevant assessments of which we should be aware?
(if yes, please bring to the appointment)
If so, please describe their participation (e.g. have staff noted any concerns? How do they play with other children? Do they join in at group time? How is their overall behaviour? Have any unusual behaviours been observed?)
Describe their participation (e.g. have teachers ever noted concerns, friendships, academic level, behaviour in the classroom, behaviour in the school yard)
(e.g. domestic violence, abuse/neglect, divorce/separation, house fire, floods, car accidents etc.)