2026 OT Parent-Caregiver Questionnaire

PARENT/CAREGIVER QUESTIONNAIRE

Occupational Therapy
GENERAL INFORMATION
Date:*

MonthDayYear
Date
Child’s Name:*
Age:*
Date of Birth:*

MonthDayYear
Date
Gender:*
Parent 1’s Name:*
Parent 1’s Relationship:*
Parent 1’s Occupation:*
Parent 1's Level of Education:*
Parent 2’s Name:
Parent 2’s Relationship:
Parent 2’s Occupation:
Parent 2's Level of Education:
PATIENT HISTORY
Who referred you for this evaluation?*
Why did they refer you?*
What are your main concerns?*
What are your goals for therapy?*
When was the problem first noticed?*
YesNo
If yes, how does your child feel about it?*
How would you describe your child?*
What are your child's strengths?*
Does your child have any special interests?*
YesNo
Does your child use any type of adaptive equipment?*
How have your child’s habits/schedule changed in the past 6 months (meals, naps, school, bedtimes)?*
FAMILY INFORMATION

List all people in household:*

Rows	Doctor	Practice	Date	Diagnosis Given/Results Found
ENT
GI
Developmental Pediatrician
Pediatrician
Neurologist
Psychologist
Psychiatrist

Rows	Frequently	Sometimes	Never
In constant motion or unable to sit still
Trouble concentrating or can't stay on task
Always runs, jumps, or stomps, rather than walking
Bumps into things or frequently knocks things over
Avoids messy play/Doesn't like to get hands dirty
Hates having hair washed, brushed, or cut
Hates having fingernails cut
Resists wearing new clothing or bothered by tags/socks
Hesitates to play or climb on playground equipment
Distressed by loud or sudden sounds
Difficulties with balance
Loses place when reading or copying from the board
Difficulty tracking objects with eyes
Mood variations, outbursts, and tantrums
Difficulty calming down
Avoids eye contact
Trouble following multistep instructions
Picky eater
Often gags on food
Reacts strongly to smells
High pain threshold
Low pain threshold

PARENT/CAREGIVER QUESTIONNAIRE

Rows	Frequency	Therapist's Name	Practice	When did therapy begin?
Speech
Applied Behavior Analysis (ABA)
Occupational
Physical
Floor Time
Music
Nutrition
Other