Parent Screening Questionnaire About Your ChildIs 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 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 detailsYour Name* Email* Your child's name* Your child's age* Your phone We will only use this to ensure you have received our email communication.If you do not wish to receive any further correspondence from Without Limits Learning please unselect the box. I am happy to receive occasional email and my child's results If you do not wish to receive any further correspondence from Without Limits Learning please unselect the box.PrivacyPlease rest assured your details are safe with us - we will never use them for spamming or selling.Your resultsYour 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.