Special Needs Questionnaire
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Student/Clients Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How old are you?
Please Select
0-5
6-9
10-15
16-22
Communication
Rows
yes
No
Non-applicable
Echolike
1
2
3
Speaks only when request
4
5
6
No speech but understands what being said
7
8
9
No speech does not understand basic commands
10
11
12
Can let you know they need help
13
14
15
Make choicesverbal
16
17
18
Make ChoicesLook in the direction
19
20
21
Make choicespointing
22
23
24
Personal Hygiene
Rows
Independently
With help
Not applicable
Dressing
25
26
27
Puts on: t-shirt / shirts
28
29
30
pants
31
32
33
socks
34
35
36
shoes
37
38
39
underwear /bra
40
41
42
jacket
43
44
45
button
46
47
48
shirt
49
50
51
wash hands
52
53
54
Bathe
55
56
57
Wash the 3 body parts
58
59
60
Rinse off
61
62
63
Dry off
64
65
66
Shampoo hair
67
68
69
Shower
70
71
72
Shaves legs
73
74
75
Under arms
76
77
78
Face
79
80
81
Females change pads
82
83
84
Toileting wipes
85
86
87
Brush teeth manual
88
89
90
electric
91
92
93
Rinse mouth
94
95
96
Comb /brush hair
97
98
99
Apply deodorant
100
101
102
Aerosol
103
104
105
Roll on
106
107
108
Vocational
Rows
Independently
With help
Not Applicable
Sweep
109
110
111
Vacuum
112
113
114
Dust
115
116
117
Laundry
118
119
120
dishwasher
121
122
123
unload
124
125
126
load
127
128
129
Put Laundry away
130
131
132
Take Trash out
133
134
135
Replace trash bags
136
137
138
Clean bedroom
139
140
141
make bed
142
143
144
dirt clothes in basket
145
146
147
Clean bathroom
148
149
150
sink
151
152
153
counter tops
154
155
156
toilet
157
158
159
shower stall
160
161
162
Groceries:unload from car
163
164
165
put away
166
167
168
Eating
Rows
Yes
No
Independently
Not Applicable
Eat
169
170
171
172
Uses utensils
173
174
175
176
Finger food
177
178
179
180
Allergic
181
182
183
184
Snacks
185
186
187
188
Usesmicro wave
189
190
191
192
stove top
193
194
195
196
Oven
197
198
199
200
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Seizures:
Yes
No
Comment on seizures (what does it look like) and allergies (food)
Behaviors :hitting , kicking, biting, banging head, uses profanity , spitting, other describe in details
Additional comments
Submit
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