PEDIATRIC OT QUESTIONNAIRE

Name of Child:

Age/Sex: Date of Contact

Birth: No.
(month|day|year)

Parent/Guardian
Name:

Home Address:

School:
(if applicable)

Doctor/ Diagnosis
Physician: :
(if applicable)

Previous OT/PT/Speech?
Where and When?

EMERGENCY CONTACT:

Name: Contact No:

Relationship
of Child:

What are your main concerns? Please consider all areas of development that apply to your
child (academics, self-care, social relationships, motor/fine/play skills, etc.)
How do these issues or challenges affect your child's everyday life and interactions with
others?

MEDICAL HISTORY

Were there any illnesses or other complications during your pregnancy?

☐ Bleeding ☐ Arthritis

☐ High Blood ☐ Infections

Pressure/Preeclampsia please specify:
________________________

☐ Depression/Anxiety ☐ Severe nausea and vomiting

☐ Preterm Labor ☐ Anemia

☐ Others:

Were you taking any specific medications/vitamin

supplements during your pregnancy? ☐ Yes ☐ No
if “Yes” please specify:

Was your pregnancy full term?

If not, please give gestational age:

Were labor and delivery normal? ☐ Yes ☐ No

What is your method of delivery? ☐ NSVD ☐ Cesarean

Child’s Birth Weight:

Were there any complications with the child?

☐ Jaundice (yellow child) ☐ Cyanosis (blue child)

☐ Umbilical Cord Compression ☐ Limpness

☐ Congenital Deformities ☐ Others:

please specify:

Was there a need for oxygen, transfusions, or tube ☐ Yes ☐ No

feeding?

Does your child have allergies? ☐ Yes ☐ No

if “Yes” please specify:

Does your child have visual/hearing problems? If ☐ Yes ☐ No

“Yes” has your child had an eye/hearing evaluation?

By whom and when?

FAMILY HISTORY OF CHILD’S MOTHER

(+) if YES, (-) if NONE

CONDITION MATERNAL PATERNAL CHILD’S

MOTHER

DIABETES

CANCER
if positive, please
specify what kind

ASTHMA
 STROKE

HIGH BLOOD
PRESSURE

OTHERS
please specify:

FAMILY HISTORY OF CHILD’S FATHER

(+) if YES, (-) if NONE

CONDITION MATERNAL PATERNAL CHILD’S FATHER

DIABETES

CANCER
if positive, please
specify what kind

ASTHMA

STROKE

HIGH BLOOD
PRESSURE

OTHERS
please specify:
 MOTOR SKILLS: MOBILITY

Can the child walk independently? ☐ Yes ☐ No

Does your child use any wheelchair/any other

assistive devices? ☐ Yes ☐ No
if “Yes” please specify:

Are there any concerns about the child’s motor skills (i.e walking, sitting, crawling)?
if “Yes” please specify:

GROSS MOTOR SKILLS

Achieved/Not Achieved
please mark (/) if achieved Age Achieved Remarks/Concerns
and (x) if not achieved

Rolls over

Sitting

Crawls

Creeps

Cruising

Standing

Walks Alone

Starts to run

Jumps in place

Walks up and down

the stairs without
alternating feet

Runs
Walks up and down
the stairs with
alternating feet

Hops

Jumps

Uses fork

Wipes nose

Pedals tricycle

Broad Jumps

Skips

FINE MOTOR SKILLS

Imitates 3 Cube
Bridge

Turns one page at a

time

Copies Circle

Handles pencil with

finger and wrist

Cuts with scissors

Catches things with

hand

Can throw balls

Child’s Hand Preference ☐ L ☐ R

Child’s Hand Dominance ☐ L ☐ R

Child’s Hand Handedness ☐ L ☐ R

Is your child clumsy or uncoordinated? ☐ Yes ☐ No

Does your child get fatigued easily? ☐ Yes ☐ No

Does your child have difficulties with handwriting? ☐ Yes ☐ No

 LANGUAGE AND COMMUNICATION

How many words does your child use? (please cite them down)

Does your child respond when his/her name is ☐ Yes ☐ No

called?

How does your child communicate? (i.e babbles, points, words)

How does your child express his/her wants and needs?

Does your child appropriately use gestures and non verbal language?
(facial expressions, body language, please specify)

Does your child make any sounds? (i.e car sounds,

animal sounds, please specify what kind)

☐ Yes ☐ No

Does your child understand simple directions? ☐ Yes ☐ No

If “Yes” what kind of instructions? How many steps? (please describe)

Do you or the others have difficulty understanding your child? If so, describe.
 BEHAVIOR AND ATTENTION

Kindly describe your child’s personality?

What are your child’s interests?

Does your child play with toys appropriately?

if not, please specify:
☐ Yes ☐ No

Is your child easily frustrated? If so, what does he/she do?

please specify:
☐ Yes ☐ No

Does your child struggle when moving to different activities ☐ Yes ☐ No

or environments?

Is your child indifferent to safety precautions?

How can you say so?

☐ Yes ☐ No
Please rate your child’s attention:

Preferred tasks Good Fair Poor

Non Preferred tasks Good Fair Poor

Academic tasks Good Fair Poor

During interactions with Good Fair Poor

others
 SELF HELP SKILLS

DRESSING
please mark (/) the corresponding boxes that apply to the child, (x) if not anymore.

DON DOFF INDEPENDENT ASSISTANCE

NEEDED

Shoes

Socks

Shirt

Pants

Underwear

Jacket

Button

Unbutton

Tie

Zip

FEEDING
please mark (/) the corresponding boxes that apply to the child, (x) if not anymore.

INDEPENDENT ASSISTANCE REMARKS/

NEEDED CONCERNS

Suck from a bottle

Suck from a straw

Drink from a cup held

for him/her

Hold and drink from a

sippy cup

Feed self without help

Drinks

Finger Feed
Holds a spoon

Scoop with a spoon

Use a fork

Use knife to spread

Use knife to cut

Eats

Do they use utensils at ☐ Yes ☐ No

every meal/snack?

Does your child refuse to ☐ Yes ☐ No

use utensils/only finger
feeds?

TOILETING
please mark (/) the corresponding boxes that apply to the child, (x) if not anymore.

INDEPENDENT ASSISTANCE REMARKS/

NEEDED CONCERNS

Wears diapers

Pees in bed

Potty (Toilet) Train

Bowel Control

Bladder Control

Others:

BATHING
please mark (/) the corresponding boxes that apply to the child, (x) if not anymore.

INDEPENDENT ASSISTANCE REMARKS/

NEEDED CONCERNS

Taking a bath
 EDUCATION

Name of School/Daycare/Center:

Current Grade/Level:

Does your child know how to read? ☐ Yes ☐ No

Does your child know how to read words in reverse? ☐ Yes ☐ No

Does your child know how to write? ☐ Yes ☐ No

Is your child having difficulty in school? ☐ Yes ☐ No

What subject/s is he/she having difficulties with?

Any other school-related concerns?

 DAILY ROUTINE
(Kindly share the routine your child follows on a daily basis)

Time Activities

Does your child have difficulties with changes in routine? ☐ Yes ☐ No

 OCCUPATIONAL THERAPY GOALS
What are the particular results or goals you aim to attain from your child's therapy
sessions?

1.

2.

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