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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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