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 90 100%
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
*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)? ______