Parent Questionnaire

Research (published in The British Journal of Occupational Therapy) 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.

    * Required field

    Your Name *

    Your Email *

    Your Phone *

    Child's Name *

    Child's Date of Birth *

    Is there any history of learning difficulties in your immediate family?
    NoYes

    Was your child conceived as a result of IVF?
    NoYes

    Were there any medical problems during the pregnancy?
    NoYes

    Was your child born early or late for term (more than 2 weeks early or more than 10 days late)?
    NoYes

    Was the birth process unusual or prolonged in any way?
    E.g. C-Section, Forceps, etc.
    NoYes

    Was your child's birth weight below 5lbs or above 9lbs?
    NoYes

    When your child was born, was there anything unusual about him/her? E.g. Distorted skull, heavy bruising, blue coloration, required intensive care, etc?
    NoYes

    Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?
    NoYes

    Was your child extremely demanding in the first 6 months of life?
    NoYes

    Did your child miss out the 'motor stage' of crawling on his or her tummy (soldier crawl)?
    NoYes

    Did your child miss out the 'motor stage' of crawling on his or her hands and knees? (If "No", how long did s/he crawl?)
    NoYes

    Was your child late at learning to walk (16 months or later would be considered late)?
    NoYes

    Was your child late at learning to talk (2-3 word phrases at 18 months or later would be considered late)?
    NoYes

    In the first 3 years of life, did your child suffer from any illnesses involving extremely high temperatures, delirium or convulsion?
    NoYes

    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?
    NoYes

    Does your child suffer from allergies?
    NoYes

    Did your child have an adverse reaction to any of his or her vaccinations?
    NoYes

    Did your child suck his or her thumb beyond the age of 5 years?
    NoYes

    Did your child continue to wet the bed, albeit occasionally, above the age of 5 years?
    NoYes

    Does your child suffer from travel sickness?
    NoYes

    Did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock ?
    NoYes

    Did your child have an unusual degree of difficulty learning to ride a bicycle?
    NoYes

    Did your child suffer from frequent ear, nose, throat or chest infections at any time in development?
    NoYes

    Does your child have difficulty catching a ball, doing forward rolls/somersaults or stand out as 'awkward' in PE classes?
    NoYes

    Does your child have difficulty sitting still for even a short period of time?
    NoYes

    If there is a sudden, unexpected noise or movement, does your child over-react?
    NoYes

    Does your child have reading difficulties?
    NoYes

    Does your child have writing difficulties?
    NoYes

    Does your child have difficulties copying from a book, board or screen?
    NoYes

    When your child is writing does s/he occasionally put letters or numbers back to front or miss letters or words out?
    NoYes

    Has your child had a diagnosis?
    NoYes

    Does your child's emotional reaction often seem to be out of proportion to the situation?
    NoYes

    Please enter below any additional information that you think may be relevant regarding your child, including any previous diagnosis info:

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    Developmental Assessments, Reflex Inhibition (INPP), Auditory Processing Disorder, APD, Dyslexia, Reading, Writing and Math Problems, Attention Deficit Disorder (ADD), ADHD, Anxiety, Panic Disorders and Behavioral Difficulties