APPENDIX A

Angelman Questionnaire

Identifying Information

1. Child's Name:

2. Parent's Name:

3. Address:

4. Child's Age:

5. How many: brothers: sisters:

6. Name of person filling out this form and relationship to child:

Medical Information

1. Age at diagnosis

2. What was the diagnosis?

_____Deletion of chromosome 15

_____Chromosomal rearrangement of mother

_____Both chromosomes (15) from father

_____No visible deletion

3. When did your child sit unsupported?

_____months

4. Has your child had a vision examination? Any vision problems?

_____yes _____no Please describe any problems.

5. Has your child had a hearing test? Any hearing problems?

_____yes _____no Please describe any problems.

6. Is your child ambulatory? If so, at what age did he/she walk?

_____yes _____no _____months

7. Does your child experience any seizures? _____yes _____no

If so: How often?

Does he/she take any medication? If yes, what types?

8. Did/does your child have any feeding problems? _____yes _____no

If yes, please describe

Communication Information:

A. Sign: Does your child use signs to communicate?

If so:

1. Do you sign to your child when talking?

_____yes _____no Please explain.

2. Does your child use signs only after seeing you use them first?

_____yes _____no Please explain.

3. Does your child use signs without seeing you sign first?

_____yes _____no Please explain

4. Please list the signs your child uses.

5. Does your child make sure he/she has your attention before signing to you?

_____yes _____no If yes, how does he/she get your attention?

6. Are your child's signs clear? Would someone who knows sign understand your child?

7. Does your child understand better when you sign, speak, or combine sign and speech?

_____sign _____speak _____sign & speak Please explain.

B. Vocalizations: Does your child vocalize? _____yes _____no

If so:

1. When does your child vocalize (what is he/she doing when they vocalize):

2. Does your child vocalize when he/she cries?

_____yes _____no Please explain.

3. What is the voice quality? (harsh, nasal sounding, guttural)

_____harsh _____nasal _____guttural _____other (please explain)

4. What makes your child laugh?

5. If your child uses words, what are they and how do they sound? (for example, does "more" sound like "mo")

C. Gestures: Does your child use them? _____yes _____no

If so:

1. Does your child use 1 finger to point?

_____yes _____no Please explain.

2. Does your child reach for something he/she wants while opening and closing his/her hand?

_____yes _____no Please explain.

3. Does your child take your hand and place it on something of interest or to get you to do something?

_____yes _____no Please explain.

4. Does your child shake or nod his/her head to indicate yes or no?

_____yes _____no Please explain.

5. Does your child round his/her lips to get you to blow bubbles or balloons?

_____yes _____no Please explain.

6. Does your child make eye contact prior to using a gesture?

_____yes _____no Please explain.

D. Other:

1. Does your child engage in pretend play (e.g. pretending to feed a doll)?

_____yes _____ no If yes, please describe.

2. If your child is currently seeing a speech-language professional? If so, what is he/she doing?

_____yes _____no Please explain.

3. Do you feel your child's communication abilities have been underestimated? If so, why?

_____yes _____no Please explain.

4. Do you feel that your child communicates more at home with you than when being assessed or working in school with his/her therapist? If so, can you give examples?

_____yes, he/she communicates more at home

_____no, he communicates consistently across environments

5. Did your child receive speech-language services prior to the age of three?

_____yes _____no

 

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Última modificación: 25 de mayo de 2007