Child Screening Questionnaire

Filling out this questionnaire will help us make an initial assessment of your child. Please leave your contact information and we will get back to you soon.

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.

This questionnaire is courtesy of www.inpp.org.il

Is there any history of learning difficulties in your immediate family?

Were there any medical problems during the pregnancy?

Was your child born early or late for term (more than 2 weeks early or more than 10 days late)?

Was your child’s birth weight below 5lbs (pounds)?

Did your child have any difficulty feeding in the first 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 in 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 ?

id your child have an unusual degree of difficulty learning to ride a bicycle?

Did your child suffer from 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 temperatures, 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?

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Your Child’s Details

Child’s Name

Child’s Date of Birth

Child Screening Questionnaire

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Your Child’s Details

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