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Child Screening Questionnaire

    Your Name*:

    Your Email:*

    Address:

    Phone Number:

    Your Child's Details:

    Child's Name:

    Child's Date of Birth:

     

    Research (published in The British Journal of Occupational Therapy, October 1998) has shown that a score of 7 or more ‘yes’ answers on the questionnaire below indicates that further investigation for underlying neuro-developmental delay is advised for children over 7 years of age.

     

    Is there any history of learning difficulties in your immediate family? YesNo
    Were there any medical problems during the pregnancy? YesNo
    Was the birth process unusual or prolonged in any way? E.g. Caesarean Section, Forceps, etc YesNo
    Was your child born early or late for term (more than 2 weeks early or more than 10 days late)? YesNo
    Was your child's birth weight below 5lbs (pounds)? YesNo
    Did your child have any difficulty feeding in the first weeks of life, or in keeping food down? YesNo
    Was your child extremely demanding in the first 6 months of life? YesNo
    Did your child miss out the 'motor stage' of crawling on his or her tummy and creeping on hands and knees? YesNo
    Was your child late at learning to walk (16 months or later would be considered late)? YesNo
    Was your child late at learning to talk (2-3 word phrases at 18 months or later would be considered late)? YesNo
    Did your child have difficulty in learning to dress himself or herself, for example, do up buttons or tie shoelaces beyond the age of 6-7 years? YesNo
    Does your child suffer from allergies? YesNo
    Did your child have an adverse reaction to any of his or her vaccinations? YesNo
    Did your child suck his or her thumb beyond the age of 5 years? YesNo
    Did your child continue to wet the bed, albeit occasionally, above the age of 5 years? YesNo
    Does your child suffer from travel sickness? YesNo
    Did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock? YesNo
    Did your child have an unusual degree of difficulty learning to ride a bicycle? YesNo
    Did your child suffer from frequent ear, nose, throat or chest infections at any time in development? YesNo
    In the first 3 years of life, did your child suffer from any illnesses involving extremely high temperatures, delirium or convulsion? YesNo
    Does your child have difficulty catching a ball, doing forward rolls/somersaults and stand out as 'awkward' in PE classes? YesNo
    Does your child have difficulty sitting still for even a short period of time? YesNo
    If there is a sudden unexpected noise, does your child over-react? YesNo
    Does your child have reading difficulties? YesNo
    Does your child have writing difficulties? YesNo
    Does your child have copying difficulties? YesNo
    Has your child had a diagnosis? YesNo
    If your child has a diagnosis, what was it, when was it given and by whom?
    Please add any additional information that you think may be relevant regarding the possible diagnosis of your child, including any previous diagnosis information:

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