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Parents Questionnaire


Child's Name*
D.O.B*
Age:*
Mothers Name:*
Fathers Name:*
Fathers Occupation:
Mother Occupation:
Siblings- Names/Ages:

General Information

  
1). Languages are spoken at home  
English
Tamil
Mandarin
Hindi
Malay/Bahasa- Indonesia Others
2) Describe your child’s speech and language problem.*
3). When was the problem first noticed?*

4). Does your child’s communication resemble any of the following:
Doesn’t speak as yet
Appears to stutter
Not using words but makes a lot of ‘speech- like’ sounds
Has a hoarse voice
Speaks in sentences not longer than 2 words ( eg, daddy go)
Makes a lot of errors with grammar – eg, tenses, plurals etc.
Speech unclear- some sounds may not be clear
( eg, ‘s’ and ‘r’ are not )
Has problems with reading and writing . Please Specify :
Tends to repeat what is said
 
5). Can your child follow simple verbal instructions at home or school?
Yes  
No Comments
6). Does your child have any difficulty with?
Walking
Running
Fine-Motor Skills
Drooling
7). Does your child have any of the following feeding difficulties?
Unable to suck-swallow ( for babies)
Difficulties making a transition from bottle feeds to semisolids and solids
Poor intake
Coughs, chokes
Unable to use a straw & / or cup
Problems biting and / or chewing
Refuses specific foods
Unable to swallow
Picky eater
Others :
 

If you 'Tick' any of the above in this feeding section, fill in the following: Feeding in a typical day looks like :
(Diet log - fill in the time, food fed and amount)

8). Does your child demonstrate any of the following?
Too sensitive to sounds
Dislikes certain Textures
Too attracted to specific colors prints and / or lights
Dislikes hair cuts, hair wash, brushing teeth etc
Loves spinning objects , flapping hands
Tends to bite or chew on objects/people
Enjoys bouncing and jumping
Resistant to changes – be it daily routine or introduction of something ‘new’

9). Any significant Medical History
Nothing significant
Frequent colds/coughs/upper respiratory infections
Ear infections
Other

10). Educational History

  
Not in school
Pre-school
Primary school
Secondary school
  Other

11). How is the child doing academically?
Not coping well
Average performance
No problems
Not Applicable
 

12). How does the child interact with others at school/outside home?

Generally shy
Does not initiate any conversation/ contact with others.
Tends to be / play alone
Does not always make eye contact
Fights with other kids
Easily bullied
Throws tantrums
Friendly and Sociable
Confident
Quiet
  Other

13). Has your child seen a Speech-Language therapist before?
Yes Please Specify :
No    
 
You can also contact us at

Integrated Speech & Swallow Works Pte Ltd (ISSW)

360 Orchard Road,
#05-02 International Building
Singapore 238869
Telephone: +65 6736 4264
Fax: +65 6736 2015
Email: info@issw.com.sg
.

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Contact ISSW Contact us for any Speech, Language, Voice or Swallowing related problem in Adults or Children.
Call us at +65 6736 4264 or send an email enquiry to us
 
 
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