Cuestionario de Comunicación Compleja Complete el Cuestionario de Comunicación Compleja Complex Communication Questionnaire Date* MM slash DD slash YYYY Parent's Name First Last Child's First Name* First Child's Last Name* Last Date of Birth* MM slash DD slash YYYY Gender Home Phone*Email* Does your child have any behavioral challenges? (check all that apply) Easily frustrated/upset Has a hard time separating from me Cannot play by themself Shows aggression (towards themself or others) Short attention span Hesitant to try new activities Struggles to transition between activities Demonstrates decreased safety awareness Other (please comment below) Additional Comments Does your child have any significant medical history? (check all that apply) Adenoidectomy Tonsillectomy Thumb sucking/finger sucking Breathing difficulties Ear infections Ear tubes Head injury Vision problems Seizures Other (please comment below) Additional Comments Later Developing Communication SkillsCan your child tell a story? (check all that apply) They can tell a story with a clear beginning, middle, and end They can relate several events of a story, but not necessarily in order I cannot follow the stories they tell Other (please comment below Additional Comments How is your child’s articulation? Their speech sounds perfect They have a few sound errors, but everyone can understand what they say People sometimes have a hard time understanding them They are difficult to understand Other (please comment below) Additional Comments How does your child follow directions? Follows familiar 1-step directions (e.g., go get your shoes) Follows familiar 2-step directions (e.g., get your shoes and then go to the door) Follows novel directions (e.g., put the ball on your head, go outside and pick a flower) Follows familiar directions at home, but struggles with academic directions like math word problems Follows directions easily at home and at school Does not follow directions Other (please comment below) Additional Comments Does your child know the words for most things? Yes, they have an excellent vocabulary They know most words, but sometimes they have trouble remembering the word for something They often have trouble remembering the words for things There are a lot of words they do not know Other (please comment below) Additional Comments How does your child express their feelings? With body language/actions (e.g., cries when upset, smiles/laughs when happy) Uses words like I’m happy/sad/mad Uses more advanced emotion names, like nervous/frustrated/embarrassed Describes how they feel and why (e.g., I’m mad at you because you grounded me for no reason) I can’t tell how my child is feeling Other (please comment below) Additional Comments How does your child comprehend what is said to them? (check all that apply) They have trouble answering questions I ask them They understand what I say except when I use vocabulary words they do not know They understand what I say except when I use figures of speech They comprehend everything that is said to them Other (please comment below) Additional Comments Does your child have difficulty participating in conversation? (check all that apply) They struggle to stay on topic They are able to discuss preferred topics only They struggle to answer questions in conversation They do not maintain eye contact appropriately They do not maintain appropriate personal space They do not understand and use humor appropriately They use a tone of voice inappropriate to the situation They are able to participate appropriately in conversation Other (please comment below) Additional Comments Can your child read? Yes, they read on grade level They can read most things but have trouble sounding out some words They have difficulty reading most words They cannot read Other (please comment below) Additional Comments Can your child write? Yes, they write on grade level They can write most things but have trouble spelling harder words They have difficulty writing most words They cannot write Other (please comment below) Additional Comments How is your child’s reading comprehension? They can retell a story and answer why and fact-based questions about it They can retell and answer fact-based questions, but they have trouble drawing conclusions about it (such as main idea and making inferences) They have difficulty answering most questions about it They have difficulty retelling stories Other (please comment below) Additional Comments
