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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)? __________________________