Parent Questionnaire Name * First Name Last Name Date * MM DD YYYY 1. When your child is lying on their tummy they: (mark one) * 1. They aren't able to lift their hear or don't tolerate being on their tummy 2. They are able to lift their head 3. They are able to lift their head and reach for toys 4. They are able to lift their head, reach for toys and roll from their tummy to their back 2. When your child is lying on their back: (mark one) * 1. They often keep their head to one side or rarely move their head from their favored position 2. They can turn their head to both sides 3. They can turn their head both ways and can kick their legs reciprocally and get hands to mouth 4. They can turn their head both ways, kick legs, get hands to mouth, and roll from back to tummy 3. What describes your child’s head control most often while they are sitting? (mark one) * 1. They are unable to, rarely able to or only briefly hold their head up on their own while being held 2. They can hold up their head only if they are being held or supported in some way 3. They can hold up their head for short bursts while they are sitting by themselves 4. They can hold up their head for most or all of the time while they are sitting by themselves 4. What describes the way your child sits on the floor most often? (mark one) * 1. They are only able to sit if they are being held or supported in some way 2. They are able to sit by themselves for a few moments at a time after being placed in sitting 3. They are able to sit by themselves for several minutes or more but only if they are placed in sitting 4. They are able to get themselves into sittin gon their own and most often sit in “W” sit, side-sit, or sit on their feet 5. They are able to get themselves into sitting on their own with their legs out in front with either straight legs, bent legs, one leg straight with the other bent, or criss-cross legs 5. What best describes the way your child sits on a seat? (mark one) * 1. They are able to sit on a seat only while being held or supported by a specialized seating system 2. They are able to sit on a seat by themselves if they are able to keep both hands on a surface 3. They are able to sit on a seat by themselves if they are able to keep one hand on a surface 4. They are able to sit on a seat by themselves with both hands free to play 6. When losing balance in sitting or standing, what does your child do most often? (mark one) * 1. They make no attempt to catch themselves 2. They make an attempt to catch themselves but are usually unsuccessful 3. They can catch themselves some of the time 4. They can catch themselves most or all of the time 7. When playing, your child will most often: (mark one) * 1. They don’t usually play 2. They can only play if they are being supported or helped 3. They can play independently when they are sitting or lying down 4. They can play independently in most positions with some safety concerns 5. They can play independently and move around safely as they play 8. How does your child most often get around home? (mark one) * 1. Transported in a device or carried by a caregiver 2. Belly crawl, back scoot, or rolling 3. Bunny hopping or bum scooting 4. Crawling reciprocally on hands and knees 5. Kneel walking 6. Walking using walls, rails, furniture, or an assistive device for support 7. Walking independently with some safety concerns 8. Walking independently and safely 9. How does your child most often move around the community for moderate distances? (mark one) * 1. Transported in a device or carried by a caregiver 2. Uses a power chair independently 3. Self-propels a wheelchair 4. Walks using a gait trainer 5. Walks independently using a walker, crutches, or cane(s) 6. Walks holding someone’s hand for safety but can walk independently at home 7. Walks with some safety concerns 8. Walks independently and safely 10. How does your child most often go up stairs? (mark one) * 1. They are carried by a caregiver 2. Crawl reciprocally, bum scoot, bunny hop, or commando crawl 3. Sidestep up independently while holding the railing or walk up while holding someone’s hand 4. Walk up independently using 2 railings and facing forward 5. Walk up independently using 1 railing and facing forward 6. Walk up independently without needing to use a railing but leads with one leg and places both feet on each step as they go up 7. Walk up independently without needing to use a rialing and alternate steps 11. How does your child most often go down stairs? (mark one) * 1. They are carried by a caregiver 2. They crawl reciprocally, bum scoot, slide, or commando crawl 3. They sidestep down independently while holding the railing or walk down while holding someone’s hand 4. They walk down independently using 2 railings and facing forward 5. They walk down independently using 1 railing and facing forward 6. They walk down independently without needing to use a railing, leading with one leg and placing both feet on each step as they go down 7. They walk down independently without needing to use a railing, alternating steps with each foot 12. From the list below, please mark activities your child is able to do independently and safely. (mark all that apply) * 1. Run 2. Jump 3. Climb a ladder (up and down safely) 4. Kick a ball 5. Stand on one foot 6. Hop on one foot 7. Hold a squat 8. Throw a ball 9. Walk up and down hills 10. Skip Thank you for completing the parent questionnaire!
