The information given in this questionnaire is confidential. Please answer as many questions as possible, as this information will assist us in helping you or your child. If you do not know the answers to any of the following questions, they can be discussed during your appointment.

Child's name *
Preferred name
Date of birth *
Complete Medicare no.
Position
Expiry
Private Health Fund
Home Address
Suburb
Postcode
Email Address *
Home telephone number
Mobile number
Parent/Carer 1's name
Parent/Carer 1's phone number
Home telephone number
Parent/Carer 2's name
Does the child live with both parents?
YesNo
If no, how much time with each?
School attended
Grade/Year
Teacher's name
From whom did you hear of our services?
Doctor's name
Doctor's address

Child's present area of difficulty

ReadingWritingSpellingNo definite preferred handCo-ordinationSpeechBehaviourDelayed DevelopmentConcentration
Any other problems?

Family History

Family and/or relative with reading problemsAmbidextrousLeft HandedPoor co-ordinationSimilar problem to child

Brothers and Sisters

Name
Age
Position in Family
Handedness
Name
Age
Position in Family
Handedness
Name
Age
Position in Family
Handedness

Birth History

Did Mother have any of the following during pregnancy?
Infectious DiseaseSevere TraumaHigh blood pressureToxaemiaMedicationOedemaHaemorrhagePregnancy difficult to maintain
Was Labour?
NormalInducedAssistedCaesareanInstruments used
Was Labour?
NoneGeneralLocalSpinal
Type of Presentation
HeadBreechFeet
Did Mother smoke during pregnancy?
YesNo
Length of Labour (hrs)
Birth Weight
Gestation (weeks)
Describe any birth complications

Motor Skills

Do you consider your child has poor motor co-ordination?
YesNo
Was your child unable to learn to run, hop, jump, skip easily?
YesNo
Was your child late to develop a preferred hand (after 2 ½)?
YesNo
Are they poor at ball games (catching/hitting) or at sports?
YesNo
Do you consider they have poor balance?
YesNo

Post Natal History

Was baby well at birth?
YesNo
Did baby have difficulty crying or breathing after birth?
YesNo
Did baby have difficulty sucking in first 24hrs?
YesNo
Was baby bottle fed?
YesNo
Was baby breast fed?
YesNo
Was disposition of baby abnormal?
YesNo
Was feeding difficult to establish?
YesNo
Did baby fail to regain birth weight by 5 days?
YesNo
Did baby have jaundice?
YesNo
Did baby have any sleeping difficulties in the first 6 months?
YesNo
Did the baby have any feeding difficulties in the first 6 months?
YesNo

Developmental History

Did baby object to lying on their front?
YesNo
Did they seem active to you?
YesNo
Did they seem to inactive/lack curiosity to you?
YesNo
Was child slow learning to role over?
YesNo
Did child omit stage of moving on floor on their tummy?
YesNo
Was child propped to learn to sit?
YesNo
Were they able to sit alone at 8 months?
YesNo
Did they shuffle around on their bottom?
YesNo
Did they not crawl on hands and knees?
YesNo
Did they walk before 10 months?
YesNo
Did they walk after 18 months?
YesNo
Was walking clumsy for a long time?
YesNo
Did they spend more than 1-2hrs daily in a playpen?
YesNo
Did they spend more than 1-2hrs daily in a walker?
YesNo

Personality

Easy to angerImpulsiveShort attention SpanLacks confidenceOver ActiveUnderactiveTries HardGives up easilyStubbornDependentSelf sufficientEasily excitedOverly sensitive emotionallyEasily lead by others

Hearing and Speech

Are you concerned about their hearing?
YesNo
Are they sensitive/upset by loud noises?
YesNo
Was development of speech considered abnormal?
YesNo
Do they have difficulty expressing themselves fluently?
YesNo
Has your child had a hearing test?
YesNo
If yes, was it normal?

General Development

As an infant did they object to being cuddled?
YesNo
Do they appear to have a high pain tolerance?
YesNo
Do they appear to have a very low pain tolerance?
YesNo
As an infant were they upset by movement/play?
YesNo
As an infant do they lack a sense of adventure?
YesNo
Was their sense of danger poorly developed by age 2?
YesNo
Were they a climber extraordinaire?
YesNo
Do they continue to have minor accidents (falls, bumps)?
YesNo
Did they have difficulty learning left from right by age 6?
YesNo
Do they get car sick?
YesNo
Do they touch everything especially when in new places?
YesNo
Are they always asking questions?
YesNo

Medical History

Please check any conditions your child has suffered
MeaslesMumpsChicken PoxGlandular FeverGerman MeaslesWhooping CoughRepeated 'colds'Glue EarEar achesMiddle ear infectionsFrequent sore throatsTonsillitisBronchitisPneumoniaMeningitisEncephalitisUrinary Tract InfectionHigh Temperatures of unknown origin
Others?
Is your child on any medication?
YesNo
If yes, please detail

Allergies

Persistently blocked noseSnuffly babyHay feverAsthmaSinusitisEczema
Known food allergies
YesNo
Other Allergies
Abnormal reactions to immunisations
YesNo

Any of the following?

ConvulsionsEpilepsyChronic diarrhoeaConstipationPoor appetiteLack of energyExcessive SweatingObesity

Injury

Head injuryConcussionBroken BonesPoisoning
Other?

Disorders of

BloodKidneysHeartLungsGastrointestinal tract

Nutrition & Diet

What beverages do they like to drink?
What vegetables and fruit do they like to eat?
What vegetables and fruit do they dislike?
List the foods they like the most
List the foods they dislike most

How often per week do they have...

Lollies
Milk Shakes
Sweet biscuits
Softdrinks
Ice creams
Potato chips
Cakes/donuts
Cordials
White bread

Typical Daily Diet

On rising
Breakfast
Mid Morning
Lunch
Mid Afternoon
Dinner
Evening

Schooling

Does your child like going to school?
YesNo
Does your child have a behaviour problem at school?
If yes, please describe
Has your child had any of the following?
Special remedial help (eg. Reading Recovery)Psychological testing
Has your child repeated a grade?
YesNo
How does your child get along with other classmates?
LikedClass clownA lonerA leaderA bully

Please list any specialists/consultants seen Eg. vision, auditory, occupational therapist, speech pathologist

Date
Institution/consultant
Specialty
Results
Date
Institution/consultant
Specialty
Results
Date
Institution/consultant
Specialty
Results

Visual History

Covers or close one eye when readingComplains of words moving on the pageComplains of eye strainInattentiveComplains of headacheLoses place when readingComplains of blurred visionComplains of blurred vision looking from desk to boardRubs eyesHolds books very closeLoses place oftenUses finger to keep placeSkips words and lines oftenShort attention span when readingTrouble learning left and rightUntidy writingReverses letters and numbersTrouble copying from board to bookMistakes words with similar beginningsDoesn't recognize the same word repeated on a pagePoor recall of visually presented materialTrouble with spelling and sight word vocabularySlow copying and completing worksheetsSeems to know material, but does poorly on written testsCan respond orally, but not in writingErases excessivelyTrouble learning basic math concepts of size and magnitudePoor reading comprehension yet good comprehension when listening
Does one eye turn in our out?
YesNo
When did you first notice this?
Have they had any previous eye exams?
YesNo
When?
Were glasses prescribed?
Has patching of one eye been prescribed?
YesNo
If yes, how long was the patch worn for?
Does child dislike bright light, especially when outside?
YesNo
Does child screw up one eye when in bright light?
YesNo