Download appendix a: questionnaire and vas forms

APPENDIX A: QUESTIONNAIRE AND VAS FORMS
Questionnaire
Effect of a Motor Control Intervention in Two-and-a-half to Six Year Old Children
Diagnosed with Idiopathic Toe-walking
Demographics:
Today’s date________________________
Child’s name_____________________________________
Boy___ Girl___
Child’s date of birth ___________________ Child’s age today_____________________
Your name and relationship to child: __________________________________________
Name of other parent or person(s) responsible for child: __________________________
Address: ________________________________________________________________
Phone number: __________________ Emergency phone number: __________________
Child’s physician: _________________________ phone number: __________________
Birth history
1.
How many weeks gestation was your child? ___________
2.
Birth weight: ___________
3.
Any complications during pregnancy yes____ no_____
4.
Birth complications: yes____ no_____
Cesarean: yes____ no_____
Multiple birth: yes____ no_____
Did he or she require oxygen or resuscitation at birth? yes____ no_____
Did he or she require hospital care more than 3 days? yes____ no_____
Developmental history and walking
1.
Age when child walked independently? ________________(months)
2.
Does your child receive speech or language intervention? yes ___ no___
3.
Is your child having difficulties with learning or attention? yes____ no_____
4.
Has your child always walked on his or her toes? yes____ no______
If not, at what age did toe-walking begin? ______________(months)
5.
Is your child able to heel-toe walk sometimes? yes____ no_____
6.
On the following line please mark your estimate how much toe-walking your
child engages in at this time:
[_____________________________________________________________]
0%
10
20
30
40
50
60
70
80
90
7.
Check problems or your concerns about your child as a result of toe-walking:
____falling*
____feet turn in (pigeon toe)
____poor balance
____feet turn out
____tight calf muscles
____leg or foot pain
____tires easily
____flat foot, no arches
____limps
____knee problems
____bunion
____teased by other children
100%
*How often does your child fall?__________________________________
Are there particular circumstances in which your child is more likely to fall?
_____________________________________________________________
8.
Have you made any efforts to change your child’s walking? yes____ no_____ If
so, what happened as a result of your efforts?_________________________________
9.
Does your child’s toe-walking behavior vary with the time of day? yes___
no____
10.
Are there any more details about your child’s walking that you would like to
add?_________________________________________________________________
Family history related to toe-walking
1.
Check family members who were “toe walkers” after the age of 3 years?
__father
__mother
__grandfather (father’s side)
__grandfather (mother’s side)
__grandmother (father’s side)
__grandmother (mother’s side)
__siblings
(how many and current ages ____________________________)
__aunts or uncles
__None or Don’t know
2.
Do any of these continue to toe walk? yes____ no_____ don’t know_____
If not, at what ages did they outgrow toe-walking?____________________________
3.
Do family members have any unusual traits or conditions that seem to be
associated with former or present toe-walking?_______________________________
_____________________________________________________________________
Health Issues
1.
List any other medical concerns that might affect physical therapy activities
(such as asthma, allergies)? ________________________________________________
_______________________________________________________________________
2.
List regular medications______________________________________________
_______________________________________________________________________
3.
Is there anything more that we should know to be able to help your child?
________________________________________________________________________
________________________________________________________________________
Visual Analog Scale For Parent Observations
Effect of a Motor Control Intervention in Two-and-a-half to Six Year Children Diagnosed
with Idiopathic Toe-walking
Patient code
__________
Session # ______________
Date__________________
[_____________________________________________________________]
0%
10
20
30
40
50
60
70
80
90
100%
Please put a mark on the line that is your estimate of how much heel-toe-walking your
child engaged in during your observations.
What circumstances may have influenced how your child has been walking: (such as being with
other children, fatigue, illness)? __________________________