Is there a history of learning difficulties in your immediate family?: Yes No

Were there any medical problems during your pregnancy?: Yes No

Was the birth process unusual or prolonged in any way (i.e. forceps, CS 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?: Yes No

Did you child have any difficult 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 any difficulty in learning to dress him/herself, for example, do up buttons or tie shoelaces beyond the age of 6 - 7 years?: Yes No

Does your child suffer from any allergies?: Yes No

Did your child have an adverse reaction to any of his/her vaccinations?: Yes No

Did your child suck his/her thumb beyond 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 in learning to ride a bicycle?: Yes No

Did your child suffer from frequent ear, nose, chest or throat 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

Please provide any additional information that you think may be relevant regarding the possible diagnosis of your child, including any previous diagnosis information::

Was there a delay in language development?: Yes No

Did your child suffer from recurrent ear infections?: Yes No

Has your child ever been investigated specifically for hearing difficulties?: Yes No

Receptive Listening: Do any of these apply to your child?

Short attention span Yes No

Distractibility Yes No

Oversensitivity to sounds Yes No

Misinterpretation of questions Yes No

Confusion of similar sounding words, frequent need for repetition Yes No

Inability to follow sequential instructions Yes No

Motor Development: Do any of these apply to your child?

Poor posture Yes No

Fidgety behaviour Yes No

Clumsy, uncoordinated movements Yes No

Messy handwriting Yes No

Poor organisational skills Yes No

Confusion between left and right Yes No

Mixes dominance (i.e. writes with right hand, plays tennis with left hand) Yes No

Poor sports skills Yes No