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ESSENCE-Q-REV Child English
Johnny Kerr
2024-09-17T13:59:14+01:00
ESSENCE-Q-REV Child English
"
*
" indicates required fields
Step
1
of
2
50%
ESSENCE-Q-REV
Name of child
*
Age of child
*
Please enter a number greater than or equal to
0
.
Child's date of birth
*
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Month
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Year
Year
2027
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Sex
*
Completed by
*
Relationship to the child
*
Date of submission
*
Day
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Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
Year
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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2008
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2002
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1981
1980
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1963
1962
1961
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1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
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1921
1920
Please take a few minutes to read the following items and check the box that is most applicable for each item.
Have you or anybody else been concerned for more than a few months regarding the child's:
1. General development
*
Yes
Maybe/A little
No
2. Motor development/milestones
*
Yes
Maybe/A little
No
3. Sensory reactions (e.g. touch, sound, light, smell, taste, heat, cold, pain)
*
Yes
Maybe/A little
No
4. Communication/language/babble
*
Yes
Maybe/A little
No
5. Activity (overactivity/passivity) or impulsivity
*
Yes
Maybe/A little
No
6. Attention/concentration/“listening”
*
Yes
Maybe/A little
No
7. Social interaction/interest in other children
*
Yes
Maybe/A little
No
8. Behaviour (e.g. repetitive, routine insistence)
*
Yes
Maybe/A little
No
9. Mood (depressed, elated/manic, extreme irritability, crying spells)
*
Yes
Maybe/A little
No
10. Sleep
*
Yes
Maybe/A little
No
11. Feeding
*
Yes
Maybe/A little
No
12. “Funny spells”/absences
*
Yes
Maybe/A little
No
If "Yes" or "Maybe/A little" to any of the above, please elaborate briefly here:
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