Create-abilities Preschool Questionnaire

PRE-SCHOOL QUESTIONNAIRE

Create-abilities
Your student has an Occupational Therapy Assessment with Nadia Brown at Create-abilities. Your knowledge and opinions of this child is important and valued. Your assistance is greatly appreciated in the completion of this questionnaire prior to the assessment. This will enable an overall insight into this child's abilities and enable the assessment to focus specifically on problem areas highlighted.
Please fill in the form below or if you prefer to print a questionnaire and post it to Create-abilities, CLICK HERE

Child's name Pre-School/Day Care Centre

Address Phone

days attended Monday Tuesday Wednesday Thursday Friday

child's key worker Director

what activities does this child avoid/dislike

what activities does this child choose & enjoy

what do you perceive this child's strengths to be

what are your primary concerns in regard to difficulties affecting this child's development & participation

does this child receive aide assistance? yes no

details & comments on strategies in place to support this child?

ATTENTION & PARTICIPATION
attention & concentration, instruction following, task completion, more adult supervision in comparison to peers, organisational skills, turn taking, behaviour, group participation-withdrawal/ impulsiveness, peer relations and
interaction, play skills
comments

PRE-WRITING & FINE MOTOR SKILLS
hand preference, pencil grip, colouring, drawing, writing name, craft, manipulating small objects, scissor skills, construction, play dough
comments

GROSS MOTOR SKILLS
confidence, co-ordination, balance, strength, endurance, outside play and participation, ability to jump, hop, run comments

VISUAL PERCEPTUAL SKILLS
puzzles, copying body movements, discriminating same & different, matching shapes/colours, recognise written name, navigate self without bumping into things when walking/running
comments

SENSORY PROCESSING
fear or avoidance of climbing equipment, impulsive & always on the go, unable to tolerate dirty hands & avoids messy play, noise sensitive, touches all objects & people more than peers, sensitive to certain types of touch, doesn't like to be bumped, poor tolerance of change in routine
comments

SELF CARE SKILLS
toileting, washing hands, jumper, socks and shoes on/off, feeding
comments

name of person completing this questionnaire
position date

please contact Nadia at Create-abilities if you wish to further discuss this child's needs on
0420 942 129 or email nadia@create-abilities.com.au
Nadia Brown, Paediatric Occupational Therapist, B.App.Sc.(OT), MHS(OT), AccOT.