Parent/Guardian Questionnaire

Please note, we do not give a formal diagnosis.

Classification of the exact type of specific learning difficulty is not undertaken by this clinic. This type of assessment would be carried out by an Educational Psychologist, should your child’s school feel that this is appropriate. Only children with a significant level of difficulty would require a formal assessment. Please discuss any concerns with your child’s teacher.

Please ensure that if your child has not had an eye examination within the past six months that you arrange this prior to your first assessment; please bring the results with you.

Your name:
Relationship to child:
Child's name:
DOB: Gender:

Tel no:
Mobile no:

G.P name:

Surgery address:
School name:
School contact:

School address:
School email:

General Health

Has your child suffered from any of the following?

Convulsions, fits or epilepsy?
High temperatures in their first 18 months?
Frequest ear infections in their first 3 years?

If yes, tick the box which indicates the age they first suffered:


0-6 months
6-12 months
12-18 months
18-24 months
2-3 years
after 3 years


0-6 months
6-12 months
12-18 months
18-24 months
2-3 years
after 3 years

Ear Infections

0-6 months
6-12 months
12-18 months
18-24 months
2-3 years
after 3 years

Have they required grommets?
If yes, please state approximately the age when they were first required:
Have they ever suffered with allergies/hypersensitives e.g. asthma, hay fever?
If yes, please give details:

Family History

Are there allergy tendencies in the family?
if yes, please state relationship to child:
Does any member of the family suffer with epilepsy?
if yes, please state relationship to child:
Does any member of the family suffer with migraine headaches?
if yes, please state who:
Has any family member ever had any reading or other specific learning difficulties?
if yes, please state who:

Childs Developmental History

Was your child born when they were due, early or late?
Please state how many weeks they were early or late:
Was the birth normal?
if no, please say what the complications were:
At what age did your child crawl?
Was crawling conventional? i.e. on hands and knees, moving opposite arms and legs
If not, what did they do? e.g. bottom shuffle, commando style etc:
At what age did they start to walk?
At what age did they begin to talk?
Were there any problems with speech?
if yes, please give details:
Was speech therapy required?
Please give details:
Do they have any problems with co-ordination?
Please give details:
Can they ride a bike?
Can they tie shoe laces?
Can they do buttons up and get dressed without help?
Can they use a knife and fork to eat?
Has your child ever suffered a significant head injury
particularly if this resulted in unconsciousness?
if yes, pleases specify, including age at which the injury occured:
Does your child confuse left and right?
Does you child still have difficulty telling the time on a clock with hands?
if yes, what are the problems:

Visual History

Does you child have regular eye checks?
Do they requrie spectacles?
Have they ever had a lazy eye or a squint,
or required patching or operations on their eyes?
if yes, please state what:

Visual Behaviour

Does your child report any of the following when reading?

Loses their place?
Loses the line?
Misses out words?
Closes one eye when reading?
Rubs eyes?
Blinks a lot?
Tilts or moves head?
Uses a finger as a marker?
Confuses letters or words?
Reverses letters or words?
Skips, re-reads or omits lines?
Reads very slowly?
Tires easily?
Short attention span?
Are they sensitive to light?
Reports that print blurs?
Reports that print shimmers, moves or falls off the page?
Print changes size?
Sees colour around words?
Do they complain of double vision?
Do they complain that their eyes hurt?
When they look at the board at school is it usually clear?
Does distance vision go blurred at times?
Do they have problems copying from the board?
Does your child suffer with frequent headaches?
If yes, please say how frequently they occur:
At what time of day and what part of the head?
Are their headaches considered to be a migraine type?

General Details

Does your child enjoy art?
Are they good at art?
Are they good at doing puzzles?
Are they good at making models?

Do they need to read the instructions to make models, or can they make them easily by looking at a picture of the model? Please give brief details:


Does your child have problems with concentation?
If yes, please give brief details here:


Does your child have difficulty remembering things they did in the past,
like holidays? or places you have visited?
Do they have difficulty remembering what they have just been asked to do?
Do they have difficulty remembering a series of instructions?
Please give any relevant details below:


Are they able to sit still?
Are they able to take turns?
Do they get upset very easily, often over something very trivial?
If the answer is yes, please give some examples:
Do they often appear to act before they think, are they very impulsive?
Do they seem to have a lack of awareness of danger?
Do they tend to take things very literally?
Do they tend to have low self esteem?


Are they able to organise what they have to do?
Do they get ready on time?
Do they have an awareness of time, a body clock, for example, if you said,
you have to be ready in 10 minutes, would they be?

We intend to monitor what effect the exercise programme is having on school progress
We would like to ask for your permission to ask your child's school to give us up to date information on your child's progress on completion of the programme, or a year after starting the programme.

Please indicate your acceptance if you are happy with this request.
Would you also be willing to complete a short update questionnaire in the future
about the changes you feel the programme has had for your child's progress.

Use the space here to give any additional information that you feel may be relevant:
Next Step. Once we have received this questionnaire we will, if required, send your child's school a
further questionnaire for completion regarding their school performance.
Please tick here to disagree to us contacting your child's school.

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