Regional Office of Education #08
27 S. State Ave., Suite 101, Freeport, IL 61032
Phone: 815.599.1408 Fax: 815.297.9032
www.roe8.com
Parental Concerns Questionnaire
P
arent Name: _________________________________ Child Name:_______________________________________
Directions: Please mark all your concerns from the following list with and X.
_
___ 1. Behavior. My child:
____ has tantrums
____ is not able to accept limits
____ resists rules or refuses to comply with
requests
_
___ 2. Socialization. My child:
____ does not play with other children
____ does not separate from me easily
____ will not work in a group
____ is left out of activities with other children
____ 3. Speech/Language. My child:
____ has unclear or garbled speech
____ has difficulty expressing wants
____ uses incomplete sentences
____ needs instructions repeated often
____ repeats what she or he says
____ doesn’t remember simple information
from day to day
____ gives inappropriate answers to questions
____
4. Self-Help. My child:
____ has toileting difficulties
____ has difficulty feeding or
dressing himself or herself
____ has difficulty following routines
_
___ 5. Attention. My child:
____ is easily distracted
____ has a short attention span
____ darts from one task to another
____ persists when asked to stop
_
___ 6. Developmental Abilities. My Child:
____ does not appear to be learning at an
average rate
____ has had delays in developmental
milestone
____ does not seem to understand well
____ acts much younger than his or her age
____ seeks much younger friends
_
___ 7. Motor. My child:
____ is clumsy
____ has difficulty using pencils, crayons, or
scissors
____ has difficulty buttoning or zipping
____ has hand/eye coordination problems
____ has poor control of body movements
_
___ 8. Hearing. My child:
____ has trouble hearing
____ asks people to repeat or talk louder
____ favors one ear over the other
____ is startled at sudden noises
____ has earaches
____ speaks loudly
____ watches a person’s face when that person
talks
_
___ 9. Vision Problems. My child:
____ has eyes that turn in
____ has eyes that turn out
____ squints
____ tilts his or her head
____ wants to sit too close to the TV
____ hold books very close to his or her face
____ blinks a lot
____ rubs his or her eyes
_
___ 10. Medical/Health Related. My child:
____ has been in the hospital _____ times
____ has had serious illnesses
____ has had accidents
