Questionnaire for Special Education

Dear Parents,
I am excited about having your child in my classroom this year. To better serve your child’s needs,
please fill out this brief questionnaire. If you can return it to me before our meeting, I can be better
prepared to answer any questions you might have. Thank you.

Name of Child: _______________________________________________

What do you enjoy most about your child?

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What do you see to be your child’s strengths?

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What activities does your child enjoy the most (e.g., sports, academic, favorite toys and games, etc.)?
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Please give a brief description of the following:

 Sensitivity: _______________________________________________

 Sense of humor: _______________________________________________

 Needs and ways to be in control: _______________________________________________

 Fears, anxieties and other problems: _______________________________________________

Academic
Child presently (circle one): likes school hates school is indifferent

What are your child’s academic strengths and favorite school activities?
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What are your goals for your child this year?

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What specific concerns do you have about your child's academic progress or behavior?
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What general questions do you have about classroom curriculum, standards, evaluation techniques, or procedures?
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What questions or concerns does your child have about school? (Complete this section with your child.)
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Does your child have any health problems that might affect his or her behavior or academic progress?
Yes_____ No_____

School problems and concern areas from parents’ point of view, and concerns teachers have reported about your
child. Include length of time any problems have been occurring.
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Is your child dealing with any personal or family issues that might affect his or her behavior or academic progress?
Yes _____ No _____

Sensory Motor
____ has no sensory or motor difficulties
____ has no visual difficulties
____ is to wear corrective lenses
____ has mild hearing difficulties
____ has substantial hearing difficulties
____ eyes do not tract together
____ has an allergy related difficulty
____ is supposed to wear a hearing aid
____ has pressure equalization (P/E) tubes
____ has fine motor movement difficulties
____ has gross motor movement difficulties
____ frequently bumps into things

Can your child ride a bike without training wheels? Yes / No At what age did they start? _____

Energy levels:

Health and Development

Please note if your child has/had any of the following health issues:

Condition Yes / No Condition Yes / No

Heart Disease Asthma
Respiratory Disease Frequent Ear Infections
Accidents or injury requiring Head injury causing loss of
emergency room/hospital treatment consciousness
Seizures High Fevers (over 103)
Diabetes, arthritis, other chronic illness Chicken pox, measles, mumps, or
other childhood diseases
Gross motor difficulties, clumsiness Speech and language issues
Other (please specify) Other (please specify)

Please rate your child’s appetite: Excellent Good Fair Poor

Please rate your child’s sleep: Excellent Good Fair Poor

Between what hours does your child sleep at night? ___________________________________________________

Does your child currently have any of the following issues?

Is easily over stimulated in play Has a short attention span

Seems overly energetic in play Seems impulsive
Lacks self-control Overreacts when faced with a problem
Seems unhappy most of the time Seems uncomfortable meeting new people
Withholds affection Requires a great deal of parental attention
Hides feelings more than peers Is more fearful than others his/her age
Very stubborn, noncompliant Defies authority frequently
Uses drugs or alcohol Has been in trouble with the law
 Has attempted to harm self or others Has learning Problems

Is there a family history of learning, developmental or emotional problems? If so please specify.

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Behavior
How would you describe your child’s temperament?

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How well does your child get along with his/her peers?

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Do you have any concerns about your child’s behavior?

How do you discipline at home? For what problem behaviors? Which motivation and learning methods
are usually effective?

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Family
Activities enjoyed as a family:

Relationship with family members (please specify):

Is there anything else you would like me to know about your child?

*Adapted from: Guada S. Castillo, LPT (SPED TEACHER) from Tomana Elementary School SPED Center

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Parents Name over Signature/Date

Prepared by:

MARIA LILIA BRENDA C. BAGAYNA

Teacher 1