Chestionar pediatric comportamental/developmental

In timp ce copilul dvs. se afl in sala de ateptare, personalul ii va cere

s-i
deseneze familia (cu excepia cazului in care el a fcut deja respectivul
desen). In
acest scop, vom pune la dispoziia sa creioane, pixuri, carioca sau orice
altceva
prefer el/ea. Este foarte util s avem o baz de discuie cu copilul dvs.,
dar dac
acesta refuz s deseneze, nu vom insista s o fac.
Pe dvs. v rugm s completai chestionarul de mai jos. Acesta ne va
ajuta s stabilim programul de tratament pentru copilul dvs. Toate intrebrile
sunt
opionale, dar v-am ruga s rspundei la cat mai multe posibil.
Numele copilului__________________________________Prefer s i se
spun_____________
Varsta________________________________Data
naterii______________________________
Adresa
stabil_______________________________________________________________
___
____________________________________________________________________
_________
Telefonul de acas________________________________Telefonul la locul de
munc al prinilor________________________________________
1. Cu cine locuiete copilul dvs.? (Bifai toate rspunsurile corecte)
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____Mama ____Tata ____Bunic/ ____Altcineva

Cate surori are?____________Ce varste au?_______________
Cai frai are?______________Ce varste au?_______________
2. Listai toate medicamentele pe care le-a luat mama copilului in perioada
graviditii
_________________________________________________________________
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_____________________________________________
3. Listai toate medicamentele pe care copilul le-a luat incepand de la
natere i pe

care vi le putei aduce aminte (inelegem c probabil nu vi le vei mai aminti

pe
toate)
_________________________________________________________________
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________________
4. Cum apreciai sntatea copilului dvs.?
___________________________________________
5. Ce mancare prefer copilul dvs.?
________________________________________________
6. Ce mancare nu-i place copilului dvs.?
____________________________________________
_________________________________________________________________
_________
7. Cate ore pe noapte doarme copilul dvs.?
__________________________________________
8. A trecut vreodat copilul dvs. printr-o experien neplcut in cabinetul
unui
doctor, dentist sau intr-un spital? Dac da, v rugm
specificai___________________________________
_________________________________________________________________
_________
9. Cum reacioneaz copilul dvs. atunci cand ii este team?
_____________________________
_________________________________________________________________
_________
10. Ce facei ca s-l ajutai pe copilul dvs. atunci cand ii este team?
______________________
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_________________________________________________________________
_________
11. Ce metode de linitire folosete copilul dvs.?
____________________________________

_________________________________________________________________
_________
12. Care sunt punctele forte ale copilului dvs.? La ce este bun el/ea?
______________________
_________________________________________________________________
_________
13. Care sunt activitile preferate ale copilului dvs.?
___________________________________
_________________________________________________________________
_________
14. Cum credei c inva cel mai bine copilul dvs.? Uitandu-se? Citind?
Ascultand?
Altfel?___
_________________________________________________________________
_________
15. Ce muzic ii place copilului dvs.?
_______________________________________________
16. Ce sarcini ii place copilului dvs. s indeplineasc acas?
____________________________
_________________________________________________________________
_________
17. Ce sarcini nu-i place copilului dvs. s indeplineasc acas?
__________________________
_________________________________________________________________
_________
18. Lucreaz copilul dvs. undeva?______Dac da, ce anume face?
________________________
19. Cheltuiete copilul dvs. banii imediat sau ii economisete?
___________________________
20. Care sunt punctele slabe ale copilului dvs.?
_______________________________________
_________________________________________________________________
_________
21. Care sunt temerile copilului dvs.?
_______________________________________________
22. Exist in prezent ceva ce copilul dvs. incearc s realizeze i care
inseamn
foarte mult pentru el?
_________________________________________________________________
_
_________________________________________________________________

_________
23. Au existat in ultimul timp evenimente stresante care credei c ar fi putut
s-l
afecteze pe copilul dvs.?
________________________________________________________________
_________________________________________________________________
_________
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_________________________________________________________________
_________
24. Au existat in ultimul timp evenimente fericite, vesele, care s produc
mandrie?
Dac da, v rugm
specificai.________________________________________________________
____
_________________________________________________________________
_________
25. Care sunt adulii semnificativi pentru copilul dvs., in afar de prinii
si? (De
exemplu, rude, vecini, profesori, preoi
etc.)_______________________________________________
_________________________________________________________________
_________
26. Cum se inelege copilul dvs. cu ceilali membri ai familiei?
__________________________
_________________________________________________________________
_________
_________________________________________________________________
_________
27. In general, ce prere avei despre copilul dvs.?
_____________________________________
_________________________________________________________________
_________
28. In general, ce prere credei c are copilul dvs. despre sine?
__________________________
_________________________________________________________________
_________
29. Ce visai pentru copilul dvs.?
___________________________________________________
_________________________________________________________________
_________________________________________________________________

__________________
30. Dac copilul dvs. merge la coal, v rugm prezentai pe scurt situaia sa
colar
recent.__
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
______________________________________________________
V rugm adugai orice informaie care considerai c ne-ar putea folosi
pentru a
v putea ajuta pe dvs. i pe copilul dvs.
__________________________________________________
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