Parent/Guardian name
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First Name
Last Name
Email
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Phone
(###)
###
####
Name of child
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Child's date of birth
MM
DD
YYYY
Has a diagnosis been given at any time ie. Dyslexia, dyspraxia, ADHD, ADD? If so, please state:
What investigations/interventions has your child received in the past?
What are the presenting symptoms?
Is there any history of learning difficulties in either parent or their families?
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Was your child conceived as a result of IVF?
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When the child's mother was pregnant, did she:
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Please select all relevant options
Was your child born approximately at term, early or late for term? Please give details:
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Was the birth process unusual or difficult in any way? If yes, please give details:
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When your child was born was he/she small or large for term? Please give birth weight if known.
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When he/she was born, was their anything unusual about him/her? i.e. the skull distorted, heavy bruising, definitely blue, heavily jaundiced, covered with calcium-type coating, or require intensive care. If yes, please give details:
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In the first 13 week of your child's life did he/she have difficultly in sucking, feeding problems, keeping food down or colic?
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In the first 6 months of your child's life, was he/she a very still baby, so still that at times you wondered if it was cot death?
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Yes
No
Between 6 and 18 months was your child very active and demanding, requiring minimal sleep accompanied by continual screaming?
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Yes
No
When your child was old enough to sit up in the pram and stand in the cot, did he/she develop a violent rocking motion, so violent that either the pram or cot actually moved?
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Yes
No
Did your child become a 'head-banger' i.e. bang his/her head deliberately into solid objects?
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Yes
No
Was your child early (before 10months) or late (later than 16 months) at learning to walk?
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Yes
No
Did he/she omit to go through the motor developmental stage of crawling on his/her tummy? (commando crawling)
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Yes
No
Did he/she omit to go throught the motor development stage of creeping on hands and knees?
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Yes
No
Was your child a bottom shuffler, or simply one day stood up and walked?
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Yes
No
Was your child late to talk? (2-3 word phrases by two years)
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Yes
No
In the first 18mths of life, did your child experience any illness involving high temperatures and/or convulsions?
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Yes
No
If yes, please give details:
Was there any sign of infant eczema or asthma?
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Yes
No
Was there any sign of other allergic responses?
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Yes
No
Was there any adverse reaction to any of the childhood vaccinations?
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Yes
No
Did your child have difficulty learning to dress him/herself?
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Yes
No
Did your child suck his/her thumb through to 5 years or more? If so, which thumb?
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Yes
No
Did your child wet the bed, albeit occasionally, above the age of 5 years?
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Yes
No
Does your child suffer from travel sickness?
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Yes
No
When your child went to the first formal school, i.e. infant school, in the first 2 years of schooling, did he/she have problems learning to read?
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Yes
No
In the first 2 years of formal schooling did he/she have problems learning to write?
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Yes
No
Did he/she have problems learning to do 'joined up' or cursive writing?
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Yes
No
Did he/she have difficulty learning to tell the time from a traditional clock face as opposed to a digital clock?
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Yes
No
Did he/she have difficulty learning to ride a two-wheeled bicycle?
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Yes
No
Was he/she an Ear, Nose and Throat (ENT) child, i.e. suffer from numerous ear infections, is a 'chesty' child or suffers from sinus problems?
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Yes
No
Did/does your child have difficulty in catching a ball, i.e. eye-hand coordination problems?
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Yes
No
Is your child one who cannot sit still, i.e. has 'ants-in-the-pants' and is continually being criticised by teachers?
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Yes
No
Does your child make numerous mistakes when copying from a book?
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Yes
No
When your child is writing an essay or news item at school, does he/she occasionally put letters back to front or miss letters or words out?
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Yes
No
If there is a sudden, unexpected noise or movement, does your child over-react?
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Yes
No
Has your child suffered from any of the following gastro intestinal problemsat regular intervals?
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Select all that apply
Has your child suffered from any of the following skin problems at regular intervals?
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Select all that apply
Has your child suffered from any of the following ear, nose and throat problems at regular intervals?
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Select all that apply
Has your child suffered from asthma induced by any of the following?
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Select all that apply
Does you child have excessive thirst?
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If yes, do his/her symptoms get worse if he/she has more than a 2 - 3 hour interval without food?
Are there any particular foods which alter his/her behaviour?
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If yes, please specify:
Do any of the following statements apply to your child?
