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

Were there any medical problems during the pregnancy?

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

Was your child born early or late for term (more than 2 weeks early or more than 10 days      late)?

Was your child's birth weight below 5lbs (pounds)?

Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?

Was your child extremely demanding in the first 6 months of life?

Did your child miss out the 'motor stage' of crawling on his or her tummy and creeping on      hands and knees?

Was your child late at learning to walk (16 months or later would be considered late)?

Was your child late at learning to talk (2-3 word phrases at 18 months or later would be      considered late)?

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?

Does your child suffer from allergies?

Did your child have an adverse reaction to any of his or her vaccinations?

Did your child suck his or her thumb beyond the age of 5 years?

Did your child continue to wet the bed, albeit occasionally, above the age of 5 years?

Does your child suffer from travel sickness?

Above 7 years of age:

Did your child find it very difficult to learn to tell the time from a traditional (as opposed to      digital) clock ?

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

Did your child suffer from frequent ear, nose, throat or chest infections at any time in      development?

In the first 3 years of life, did your child suffer from any illnesses involving extremely high      temperatures, delirium or convulsion?

Does your child have difficulty catching a ball, doing forward rolls/somersaults and stand      out as 'awkward' in PE classes?

Does your child have difficulty sitting still for even a short period of time?

If there is a sudden unexpected noise, does your child over-react?

Does your child have reading difficulties?

Does your child have writing difficulties?

Does your child have copying difficulties?

Additional Info:

Has your child had a diagnosis?

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

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Your Name:    Email Address:

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Child's Date of Birth: // - DD/MM/YYY

Please only submit the questionnaire if you are resident in the UK or intend to travel to the UK for further assessment.

* please note: a copy will also be sent to a representative of INPP