Questionnaire for parents with children aged 5-9

This questionnaire will help us to understand your child’s hand and arm function. Please fill in the questionnaire based on your child’s current condition and abilities. It does not matter which hand or arm is affected. Each question has a choice of answers. Please answer all questions by choosing the answer that best describes your child’s ability to perform that task.

The completion of this questionnaire is voluntary and all the information that you give us will be treated with the strictest confidence.

Therapy questionnaire

Note: Questions marked by * are mandatory

*This is a mandatory field. Child's name

*This is a mandatory field. Date of birth

*This is a mandatory field. Name of person filling in questionnaire and relationship to child

*This is a mandatory field. Name of your child’s condition

	Right	Left	Both
*This is a mandatory field. Which of your child’s hands or arms is affected?
*This is a mandatory field. Is your child mainly right or left handed?

* Spam Guard: Is water wet or dry?