Parent Screening Questionnaire About Your ChildIs there any history of learning difficulties in your immediate family?YesNoWere there any medical problems during the pregnancy?YesNoWas the birth process unusual or prolonged in any way? E.g. CS, ForcepsYesNoWas your child born early or late for term (more than 2 weeks early or more than 10 days late)?YesNoWas your child's birth weight below 5lbs (pounds)?YesNoDid your child have any difficulty feeding in the first weeks of life, or in keeping food down?YesNoWas your child extremely demanding in the first 6 months of life?YesNoDid your child miss out the 'motor stage' of crawling on his or her tummy and creeping on hands and knees?YesNoWas your child late at learning to walk (16 months or later would be considered late)?YesNoWas your child late at learning to talk (2-3 word phrases at 18 months or later would be considered late)?YesNoDid 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?YesNoDoes your child suffer from allergies?YesNoDid your child have an adverse reaction to any of his or her vaccinations?YesNoDid your child suck his or her thumb beyond the age of 5 years?YesNoDid your child continue to wet the bed, albeit occasionally, above the age of 5 years?YesNoDoes your child suffer from travel sickness?YesNoDid your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock?YesNoDid your child suffer from frequent ear, nose, throat or chest infections at any time in development?YesNoIn the first 3 years of life, did your child suffer from any illnesses involving extremely high temperatures, delirium or convulsion?YesNoDoes your child have difficulty catching a ball, doing forward rolls/somersaults and stand out as 'awkward' in PE classes?YesNoDoes your child have difficulty sitting still for even a short period of time?YesNoIf there is a sudden unexpected noise, does your child over-react?YesNoDoes your child have reading difficulties?YesNoDoes your child have writing difficulties?YesNoDoes your child have copying difficulties?YesNoHas your child had a diagnosis?YesNoYour detailsYour Name*Email* Your child's name*Your child's age*Your phoneWe will only use this to ensure you have received our email communication. I am happy to receive occasional email and my child's results If you do not wish to receive any further correspondence from Without Limits Learning please unselect the box.PrivacyPlease rest assured your details are safe with us - we will never use them for spamming or selling.Your resultsYour results will be emailed out to you within 5 working days. Please check your spam folder for this and drag it to your inbox as some email settings may accidentally filter us out. If for some reason you have not heard from us - give us another email.
