0114 2451502
info@kinesisconsultancy.com
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Children’s Questionnaire
Is there any history of learning difficulties in your immediate family?
Yes
No
Was your child conceived as a result of IVF?
Yes
No
Were there any medical problems during the pregnancy?
Yes
No
When you were pregnant, did you have any medical problems? e.g. High blood pressure, excessive vomiting, threatened miscarriage, severe viral infection, severe emotional stress, please state
Did you smoke during pregnancy?
Yes
No
Did you drink alcohol during pregnancy?
Yes
No
Did you have a bad viral infection in the first 13 weeks of your pregnancy?
Yes
No
Were you under severe emotional stress at any time, but particularly in the first 12 weeks of your 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 the birth process unusual or difficult in any way? If yes, please give details
Was your child's birth weight below 5lbs (pounds)?
Yes
No
When he/she was born, was there anything unusual about him/her? i.e. the skull distorted, heavy bruising, definitely blue, heavily jaundiced, covered with a calcium-type coating or require intensive care. If yes, please give details
Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?
Yes
No
When he/she was born, was there anything unusual about him/her?In the first 13 weeks of your child’s life, did he/she have difficulty in sucking, feeding problems, keeping food down or colic? If yes, please give details
Was your child breast fed?
Yes
No
How long was your child breast fed for?
In the first 6 months of your child’s life, was he/she a very still baby, so still that at times you wondered if it was a cot death?
Yes
No
Between 6 months and 18 months, was your child very active and demanding, requiring minimal sleep accompanied by continual screaming?
Yes
No
When your child was old enough to sit up in the pram and stand up in the cot, did he/she develop a violent rocking motion, so violent that either the pram or cot was actually moved?
Yes
No
Did your child become a ‘head-banger’ i.e. bang his/her head deliberately into solid objects?
Yes
No
Was your child extremely demanding in the first 6 months of life?
Yes
No
Did he/she go through the motor developmental stage of crawling on his/her tummy? (commando crawling)
Yes
No
Did he/she go through the motor developmental stage of creeping on hands and knees?
Yes
No
Or was your child a bottom shuffler, or simply one day stood up and walked?
Yes
No
Was your child early (before 10 months) or late (later than 16 months) at learning to walk?
Early
Late
Was your child late at learning to talk (2-3 word phrases at 18 months or later would be considered late)?
Yes
No
In the first 18 months of life, did your child experience any illness involving high temperatures and/or convulsions? If yes, please give details:
Was there any sign of infant eczema or asthma?
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 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 copying difficulties?
Yes
No
Does your child have writing difficulties?
Yes
No
Has your child had a diagnosis?
Yes
No
Please enter any additional information that you think may be relevant regarding the possible diagnosis of your child, including any previous diagnosis info:
Auditory
Was there a delay in language development?
Yes
No
Did your child suffer from recurrent ear infections?
Yes
No
Receptive Learning
Do any of these apply to your child?
Short attention span
Distractibility
Oversensitivity to sounds
Misinterpretation of questions
Confusion of similar sounding words, frequent need for repetition
Inability to follow sequential instructions
Motor development
Do any of these apply to your child?
Poor posture
Fidgety behaviour
Clumsy uncoordinated movements
Messy handwriting
Poor organisational skills
Confusion between left and right
Mixed dominance (i.e. writes with right hand, plays tennis with left hand)
Poor sports skills
Your Details
Enter the following details and a representative of The Kinesis Consultancy will contact you in due course:
Your Name
*
Email Address
*
Your Phone Number
*
Your Address
*
Child's Name
*
Child's Date of Birth (dd/mm/yyyy)
*
Please only submit the questionnaire if you are resident in the UK or intend to travel to the UK for further assessment
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0114 2451502
info@kinesisconsultancy.com
