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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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