Child Screening 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 neuromotor immaturity is advised for children over 7 years of age.

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

Yes                      No

 

Were there any medical problems during pregnancy?

Yes                      No

 

Was the birth process unusual or prolonged in any way? E.g. CS, Forceps, etc.

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

 

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

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 difficultly 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

If you have answered more than 7 questions with 'Yes', please call or email Sophie today, to arrange a

free Initial Consultation, where a more thorough investigation will ascertain the suitability of the

Reflex Stimulation Programme for your child

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