The Learning Clinic

Your Name (required)
 

Your Email (required)
 

Your telephone number
 

Child’s date of birth  

Were there any medical problems during the pregnancy? Yes No

Was the child born either before or after term (more than 2 weeks early or more than 10 days late)? Yes No

Were there any complications at birth e.g CS, forceps, breech presentation? Yes  No

Was your baby small for term (birth weight below 5Lbs) ? Yes  No

Did your child have any difficulty in the first few weeks of life feeding, sucking or keeping down food?  Yes No

Was your child extremely demanding in the first 6 months of life?  Yes No

Did your child miss out on crawling?  Yes No

Was your child slow at learning to walk (normally 12 to 16 months) ?  Yes No

Did your child experience speech difficulties?  Yes No

Was your child prone to Ear/ Nose/ Throat problems?  Yes No

In the first 3 years of life, did your child have any serious illness or incidents involving high temperature and/or convulsions ?  Yes No

Did your child have an adverse reaction to any of his or her vaccinations?  Yes No

Does your child have allergies ?  Yes No

Did your child thumb suck beyond the age of 5 years?  Yes No

Did your child experience bedwetting after 5 years of age?  Yes No

Does your child suffer from travel sickness?  Yes No

Did your child have difficulty in learning to dress or tie shoelaces?  Yes No

Did your child have difficulty learning to read a clock face?  Yes No

Did your child have difficulty learning to ride a bike?  Yes No

Does your child have difficulty catching a ball?  Yes No

Does your child find it difficult to sit still or is easily distracted?  Yes No

If there was a sudden unexpected noise, does your child over-react?  Yes No

Does your child experience regular headaches?  Yes No

Does your child have reading difficulties?  Yes No

Does your child have writing difficulties?  Yes No

Does your child have copying difficulties?  Yes No

Does your child have difficulties organising school work or completing home work?  Yes No

Is there any history of reading difficulties in the family?  Yes No

Additional comments/queries