PARENT INTERVIEW FORM

PORTSMOUTH SCHOOL DEPARTMENT

PARENT INTERVIEW FORM

Child’s Name: ______________________________________________ Today’s Date: ____/_____/______

Male __ Female __ Home Phone __________ Work Phone __________ Child’s Birth Date: ____/____/____

Street Address: _____________________________________________ Child’s Age in Years: ___________

Mailing Address: ___________________________________________ Child’s Age in Months: __________

City: ________________________ State ______ Zip Code _________ Child’s Wt. At Birth: ___lbs. ___ozs.

Elementary school this child will attend: ________________________________________________________

Father’s Name: ___________________________ Age: ___ Occupation: _____________ Education: ________

Mother’s Name: __________________________ Age: ___ Occupation: _____________ Education: ________

Number of older brothers and sisters: ______ Number of other people in the home: _______

Younger brothers and sisters:

Name _______________________ Birth Date __/__/__ Name ____________________ Birth Date __/__/__

Was there anything unusual about the pregnancy with this child? _____________________________________

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Did this child require any special medical care, or hospitalization, at birth or during the first month after birth? Yes ___ No ___ If yes, please explain: _________________________________________________________

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Has this child ever been in the hospital or been seriously ill at home? Yes ___ No ___ If yes, please explain: _________________________________________________________________________________________

Has this child ever had a serious accident? Yes ___ No ___ If yes, please explain: _______________________

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When was the last time this child was seen by a doctor? ___________ Dr.’s Name: _____________________

Briefly, what was the reason? _________________________________________________________________

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Is this child on any medication? Yes ___ No ___ If yes, please list medication(s) ________________________

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At what age did this child begin walking (if this is a guess, please label as such) _________________________

Is this child toilet trained? No ____ Yes ____ If yes, at what age was toilet training complete? ____________

Please check the appropriate answer. Yes No

Has this child ever had any ear/hearing examination or treatment? ÿ ÿ

If yes, who did the exam? __________________________ When was the exam done?

_______________________ What were the results? ___________________________

Does this child:

1. Seem to have difficulty hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

2. Turns the television volume up louder than other members of the family do?. ÿ ÿ

3. Seem to favor one ear over the other? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

4. Jump or appear to be more startled than others if there is a sudden noise?. . . ÿ ÿ

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PAGE TWO

5. Seem to hear you if you talk in a whisper?. . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

6. Make you talk loudly or repeat frequently?. . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

7. Have a history of ear infections?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

If yes, how frequent are the infections? _____________________________

What is the prescribed treatment? _________________________________

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Yes No

Has this child ever had a vision examination or treatment? . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

If yes, who administered the exam? ____________________When was it administered?

____________________________ What were the results? _______________________

Does this child:

1. Seem to have difficulty seeing small lines or pictures? . . . . . . . . . . . . . . . . . ÿ ÿ

2. Seem to have a problem seeing things far away? . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

3. Squint?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

4. Wear glasses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

5. Have eyes that turn in?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

6. Have eyes that turn out? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ

At what age did this child first begin to speak? Give approximate age if you do not remember exact age:

First words _______________ Two or three words together ______________ Sentences _________________

Please check the best response.

Does this child:

1. Talk a lot? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ

2. Seem to speak as well as his or her peers? . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ

3. Speak so that you can understand him or her? . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ

4. Speak so that other adults understand him or her? . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ

5. Speak so that other children understand him or her? . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ

If this child does not talk, does he or she:

1. Make any sounds? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ

2. Use gestures to communicate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ

Do you think this child has a problem: Yes No

1. Making sounds?. . . . . . . . . . . . ÿ ÿ Example:________________________________________

2. Putting words together?. . . . . . ÿ ÿ Example:________________________________________

3. With the way his or her

voice sounds?. . . . . . . . . . . . . . ÿ ÿ Example:________________________________________

4. Repeating sounds or words

too often?. . . . . . . . . . . . . . . . .ÿ ÿ Example:________________________________________

What language(s) is spoken most frequently in the child’s home? _____________________________________

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PAGE THREE

Do you notice, or has a doctor reported, any of the following in this child:

ÿ Asthma ÿ Frequent fevers ÿ Headaches ÿ Overtired or Lacking Pep

ÿ Indigestion ÿ Sinus trouble ÿ Nightmares ÿ Heart Trouble

ÿ Constipation ÿ Nose bleeding ÿ Thumbsucking ÿ Difficulty Hearing

ÿ Diarrhea ÿ Bed wetting ÿ Nail Biting ÿ Difficulty Seeing (blinks, squints,

ÿ Vomiting ÿ Allergies ÿ Epilepsy rubs eyes)

ÿ Other physical problems (explain): ________________________________________________________

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Please check the best answer.

Can this child:

1. Walk up and down stairs, unassisted, with both feet on each tread?. . . ÿ ÿ ÿ ÿ

2. Walk up stairs using alternate feet and railing or other support? . . . . . . ÿ ÿ ÿ ÿ

3. Walk up stairs using alternate feet, and with no support? . . . . . . . . . . . ÿ ÿ ÿ ÿ

4. Walk down stairs, one foot per tread, using rail or other support? . . . . . ÿ ÿ ÿ ÿ

5. Walk up and down stairs, one foot per tread, with no support? . . . . . . . ÿ ÿ ÿ ÿ

6. Roller skate, ride a bicycle, or jump rope? . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

7. Climb fences or trees? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

Does this child:

1. Sing short songs or commercial jingles? . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

2. Cry or whine?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

3. Seem to be unusually quiet?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ÿ ÿ ÿ ÿ

4. Repeat actions or words needlessly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

5. Pay attention to what you say or do? . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

6. Make up little games? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

7. Seem to be restless or fidgety?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

8. Seem to be happy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

9. Say “I can’t” without even attempting the task? . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

10. Have temper tantrums? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

11. Seem to be a leader?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

12. Cry when not able to have his or her own way?. . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

13. Move slowly?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

14. Speak in long sentences? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

15. Act without reason, on the spur of the moment? . . . . . . . . . . . . . . . . . . .ÿ ÿ ÿ ÿ

16. Play well with other children? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

17. Get upset easily? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

18. “Rock” his or her body? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

19. Use “big” words? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

20. Have many unusual or different ideas? . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

21. Seem to have any friends? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÿ ÿ ÿ ÿ

PARENT INTERVIEW FORM

PAGE FOUR

What is this child’s favorite thing to do at home? ______________________________________________

Does he or she have any favorite games or toys? _______________________________________________

Does he or she prefer to play alone or with others? _____________________________________________

How old are this child’s favorite playmates?(Note any relationships) _______________________________

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What kind of things does this child do that bother your? ________________________________________

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Does this child have any special fears (dogs, darkness, etc.)? ____________________________________

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Are there things this child does that you think are unusual? ______________________________________

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Do you have any special concerns about this child? ____________________________________________

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Does anyone read stories to this child? _______ If yes, who? ___________________________________

What kind of stories does this child like? ____________________________________________________

What TV shows does this child watch? ______________________________________________________

About how many hours a day? ____________________________

Has this child ever been to a nursery school or day care center? __________________________________

Where? ____________________________________ When? ____________________________

What would you like this child to learn in school? _____________________________________________

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Does this child display any special talents in areas such as music, performing for others, leading other children, engaging in physical activities? If yes, please explain. __________________________________

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Is there any other information that will help us understand this child? ______________________________

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Form completed by: Print name __________________________ Signature ________________________

Relationship to child: ___________________________________________

Thank you for your time in filling out this questionnaire.

IF YOUR CHILD IS ENTERING KINDERGARTEN:

Are you concerned about your child’s readiness for school? _________ If yes, what are your reasons for concern? _________________________________________________________________________________

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