Parent Screening Questionnaire – Without Limits Learning

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Parent Screening Questionnaire

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Parent Screening Questionnaire

About Your Child

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

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 Other

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

Did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock?

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

Does your child have difficulty catching a ball, doing forward rolls/somersaults and stand out as 'awkward' in PE classes?

Yes No

Does your child have difficulty sitting still for even a short period of time?

Yes No

If there is a sudden unexpected noise, does your child over-react?

Yes No

Does your child have reading difficulties?

Yes No

Does your child have writing difficulties?

Yes No

Does your child have copying difficulties?

Yes No

Has your child had a diagnosis?

Yes No

Your details

Name

Your child's name

Your child's age

Email

Your phone

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I am happy to receive occasional email and my child's results

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Your results

Your results will be emailed out to you within 5 working days. Please check your spam folder for this and drag it to your inbox as some email settings may accidentally filter us out. If for some reason you have not heard from us - give us another email.

We believe that every person has the potential to reach their greatness. We equip parents, teachers and professionals with tools to maximise their impact and maintain their wellbeing.

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Recognising Primitive Reflexes in the Classroom
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