Child Screening Questionnaire (copyright INPP, Chester)

Is there any history of learning difficulties in your immediate family?	Yes No
Were there any medical problems during the pregnancy?	Yes No
Was the birth process unusual or prolonged in any way? E.g. CS, Forceps, etc.	Yes No
Was your child born early or late for term (more than 2 weeks early or more than 10 days late)?	Yes No
Was your child's birth weight below 5lbs (pounds)?	Yes No
Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?	Yes No
Was your child extremely demanding in the first 6 months of life?	Yes No
Did your child miss out the 'motor stage' of crawling on his or her tummy and creeping on hands and knees?	Yes No
Was your child late at learning to walk (16 months or later would be considered late)?	Yes No
Was your child late at learning to talk (2-3 word phrases at 18 months or later would be considered late)	Yes No
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?	Yes No
Does your child suffer from allergies?	Yes No
Did your child have an adverse reaction to any of his or her vaccinations?	Yes No
Did your child suck his or her thumb beyond the age of 5 years?	Yes No
Did your child continue to wet the bed, albeit occasionally, above the age of 5 years?	Yes No
Does your child suffer from travel sickness?	Yes No
After the age of 7, did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock ?	Yes No
After the age of 7, did your child have an unusual degree of difficulty learning to ride a bicycle?	Yes No
Did your child suffer from frequent ear, nose, throat or chest infections at any time in development?	Yes No
In the first 3 years of life, did your child suffer from any illnesses involving extremely high temperatures, delirium or convulsion?	Yes No
If aged over 7, does your child have difficulty catching a ball, doing forward rolls/somersaults and stand out as 'awkward' in PE classes?	Yes No
If aged over 7, does your child have difficulty sitting still for even a short period of time?	Yes No
If aged over 7, does your child over-react to a sudden unexpected noise?	Yes No
If aged over 7, does your child have reading difficulties?	Yes No
If aged over 7, does your child have writing difficulties?	Yes No
If aged over 7, does your child have copying difficulties?	Yes No
Total number of 'yes' answers: *
Please give any additional information that you think may be relevant regarding the possible diagnosis of your child, including a summary of any previous diagnosis:
Today's date:
Child's date of birth:
Your email address: *