Screening questionnaire

Children’s Developmental Screening Questionnaire

Please complete the questionnaire as accurately as possible. If you are unsure about a question you may leave it blank or add details in the comment sections.

This questionnaire gathers developmental information that may help determine whether a Neurodevelopmental Reflex Integration assessment may be appropriate for your child. It is not a diagnostic tool.

Child Details

Child’s Name

Date of Birth

Parent / Guardian Name

Phone

Address

Has a diagnosis been given at any time (e.g. Dyslexia, Dyspraxia, ADHD, ADD)?

If so, please state

Is your child currently taking any prescribed medication?

What investigations/interventions has your child received in the past?

What are the presenting symptoms?

Part 1 – Neurological

1. Is there any history of learning difficulties in either parent or their families?
YesNo

2. Was your child conceived as a result of IVF?
YesNo

3. When you were pregnant, did you have any medical problems? Please describe

3a. Did you smoke during pregnancy?
YesNo

3b. Did you drink alcohol during pregnancy?
YesNo

3c. Did you have a viral infection in the first 13 weeks of pregnancy?
YesNo

3d. Were you under severe emotional stress during pregnancy?
YesNo

4. Was your child born early, at term or late? Please describe

5. Was the birth process unusual or difficult?
YesNo

If yes, please give details

6. Was your child small for term at birth?
YesNo

Birth weight (if known)

7. Was there anything unusual about your child at birth?
YesNo

If yes, please give details

8. In the first 13 weeks did your child have feeding or sucking difficulties?
YesNo

Was your child breastfed?
YesNo

If yes, for how long?

9. In the first 6 months was your child unusually still?
YesNo

10. Between 6 and 18 months was your child extremely active or demanding?
YesNo

11. Did your child develop a violent rocking motion in the pram or cot?
YesNo

12. Did your child become a head-banger?
YesNo

13. Was your child early or late learning to walk?
YesNo

14. Did your child omit crawling on the tummy?
YesNo

15. Did your child omit creeping on hands and knees?
YesNo

16. Was your child late learning to talk?
YesNo

17. Did your child have illness with high temperature or convulsions?
YesNo

If yes, please describe

18. Was there eczema or asthma?
YesNo

Were there other allergic responses?
YesNo

19. Was there adverse reaction to childhood vaccinations?
YesNo

20. Did your child have difficulty learning to dress independently?
YesNo

21. Did your child suck their thumb beyond age 5?
YesNo

If yes, which thumb?
RightLeft

22. Did your child wet the bed after age 5?
YesNo

23. Does your child suffer from travel sickness?
YesNo

24. Did your child have difficulty learning to read?
YesNo

25. Did your child have difficulty learning to write?
YesNo

Did your child have difficulty learning cursive writing?
YesNo

26. Did your child have difficulty telling time on a clock face?
YesNo

27. Did your child have difficulty learning to ride a bicycle?
YesNo

28. Has your child suffered frequent ear, nose or throat infections?
YesNo

29. Does your child have difficulty catching a ball?
YesNo

30. Does your child have difficulty sitting still?
YesNo

31. Does your child make mistakes copying from books?
YesNo

32. Does your child reverse letters or miss letters when writing?
YesNo

33. Does your child overreact to sudden noise or movement?
YesNo

Please add any extra information

Part 2 – Nutritional

Gastrointestinal problems

ColicTummy pains or windUnusual bowel patternsRecurrent constipationDiarrhoea

Skin problems

EczemaDry patches on face or armsNutmeg grater skinDermatitis

Other skin issues

Ear, Nose and Throat problems

Mouth ulcersBad breathTonsillitisEaracheSinusitisPersistent runny noseSnoringMouth breathingHay fever

Asthma induced by

ExerciseInfectionDustMouldAnimalsFood

Other asthma triggers

Does your child suffer excessive thirst?
YesNo

Do symptoms worsen if your child goes more than 2–3 hours without eating?
YesNo

Do particular foods alter behaviour?
YesNo

If yes, please specify

Part 3 – Auditory

Developmental History

Delay in motor developmentDelay in language developmentRecurring ear infectionsInvestigated for hearing difficulties

Receptive Listening

Short attention spanDistractibilityOversensitive to soundsMisinterpretation of questionsConfusion of similar sounding wordsDifficulty following sequential instructions

Level of Energy

Tiredness at end of dayHyperactivityTendency towards depression

Expressive Listening

Flat voiceHesitant speechWeak vocabularyPoor sentence structureCannot sing in tuneLetter reversalsPoor reading comprehensionPoor reading aloudPoor spelling

Behavioural and Social Adjustment

Low frustration tolerancePoor self-imageDifficulty making friendsWithdrawal from othersLow motivation in schoolworkImmaturityIrritabilityShyness

How did you hear about INPP?

Date questionnaire completed

Please add any additional information relevant to your child’s presenting problems

Consent

I consent to MiLuce Clinic collecting and processing the information provided in this questionnaire for the purpose of responding to my enquiry and considering whether a developmental assessment may be appropriate. I understand that this information will be handled in accordance with the Privacy Policy.