Parental Questionnaire

Research (published in the British Journal of Occupational Therapy October 1998) 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. If 7 or more positive answers are scored on the questionnaire please phone Anne-Laure to discuss the results further. Alternatively fill in the questionnaire and click on the form at the bottom to submit the information to us. This information will be held in the strictest confidence.

---

Qn	YES	NO
1			Is there any history of learning difficulties in your immediate family?
2			Were there any medical problems during the pregnancy?
3			Was the birth process unusual or prolonged in anyway?
4			Was the child born early or late (more than 2 weeks early or more then 10 days late)?
5			Was your child's birth weight below 5 lbs?
6			Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?
7			Was your child extremely demanding in the first 6 months of life?
8			Was your child late at learning to walk? (16 months or later would be considered late)
9			Was you child late at learning to talk? (2-3 word phrases at 18 months or later would be considered late)
10			Did your child have any difficulty in learning to dress him or herself, do up buttons or tie shoelaces beyond the age of 6-7 years?
11			Does your child suffer from allergies?
12			Did your child have an adverse reaction to any vaccination?
13			Did your child suck his or her thumb beyond the age of 5 years?
14			Did your child continue to wet the bed, albeit occasionally, above the age of 5 years?
15			Does your child suffer from car sickness?
16			Did your child find it very difficult to learn to tell the time from a traditional (as opposed to a digital) clock?
17			Did your child have an unusual degree of difficulty learning to ride a bicycle?
18			Did your child suffer from frequent ear, nose, throat or chest infections?
19			In the first 3 years of life, did your child suffer from any illnesses involving extremely high temperature, delirium or convulsion?
20			Does you child have difficulty catching a ball, or stand out as 'awkward' in PE classes?
21			Does your child have difficulty sitting still even for short periods of time?
22			If there is a sudden unexpected noise, does your child over-react?
23			Does your child have reading difficulties?
24			Does your child have writing difficulties?
25			Does your child have copying difficulties?

---

Your Name
Your Childs Name
Your Address
Your Postcode
Your Contact Number
Your Contact Email