Name: E-Mail Address: Telephone number Child's name: Child's date of birth: Is there any history of learning difficulties in your
immediate family? Were there any medical problems during pregnancy? Was the birth process unusual or prolonged in any way?
(e.g. CS, forceps, etc) Was your child born early or late for term? (more than
2 weeks early or more than 10 days late) Was your child'sbirth weight below 5lbs ( 2.25kg) Did your child have any difficulty feeding in the first
few weeks of life, or in keeping food down? Was your child extremely demanding in the first 6 months
of life? Did your child miss out the 'motor stage' of
crawling on his or her tummy and creeping on hands and knees? Was your child late at learning to walk? (16 months
or later would be considered late) Was your child late at learning to talk? (2-3 word
phrases at 18 months or later would be considered late) Did your child have difficulty learning to dress himself
or herself, for example, do up buttons or tie shoelaces beyond the age of 6-7 years? Does your child suffer from allergies? Did your child have an adverse reaction to any of his
or her vaccinations? Did your child suck his or her thumb beyond the age
of 5 years? Did your child continue to wet the bed, albeit occasionally,
above the age of 5 years? Does your child suffer from travel sickness? Did your child find it very difficult to learn to tell
the time from a traditional (as opposed to digital) clock? Did your child have an unusual degree of difficulty
learning to ride a bicycle? Did your child suffer form frequent ear, nose, throat
or chest infections at any time in development? In the first 3 years of life, did your child suffer
from any illnesses involving extremely high temperature, delirium or convulsion? Does your child have difficulty catching a ball, doing
forward rolls/somersaults and stand out as 'awkward' in PE classes? Does your child have difficulty sitting still for even
a short period of time? If there is a sudden unexpected noise, does your child
over-react? Does your child have reading difficulties? Does your child have writing difficulties? Does your child have copying difficulties? Any comments or particular concerns?
