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Parent Questionnaire

Step 1 of 4

25%

Please complete this questionnaire with the correct information so helping me plan the most appropriate testing protocol for your child. It is best though not essential if both parents are present for the examination and the case discussion that follows as it can be challenging for one parent to convey all the necessary information about the child to the other parent.

Many thanks in advance.
Child’s full name
Date of birth
Home address
Contact phone number
Email
School
Current year at school
Who referred you here?
List your concerns regarding your child’s performance at school
When did you first notice any issues?
Has your child been given a diagnosis at any time? (ie dyslexia, dyspraxia, ADHD, ADD)
Has your child received any other investigations or interventions in the past? Please describe these
Has there been any previous visual care? Please describe these
Does your child take any medication? If so, what for?
Does your child have any allergies or food intolerances?
Please indicate yes or no or sometimes to the following symptoms:

Visual Symptoms
Headaches with close work or school work
- Yes
- No
- Sometimes
Blurry distance vision
- Yes
- No
- Sometimes
Blurry near vision
- Yes
- No
- Sometimes
Eyes slow to focus from near to far away or far away to near
- Yes
- No
- Sometimes
Holds book close to read
- Yes
- No
- Sometimes
Eyes hurt or ache with close work or school work
- Yes
- No
- Sometimes
Words move, run together or jump about
- Yes
- No
- Sometimes
Eye turns
- Yes
- No
- Sometimes
Blinks excessively
- Yes
- No
- Sometimes
Covers one eye when doing close work
- Yes
- No
- Sometimes
Loses their place when reading
- Yes
- No
- Sometimes
Misreads words, letters or numbers
- Yes
- No
- Sometimes
Uses finger to keep place when reading
- Yes
- No
- Sometimes
Misreads words, letters or numbers
- Yes
- No
- Sometimes
Uses their finger to keep their place when reading
- Yes
- No
- Sometimes
Problems copying accurately from a book or from the board
- Yes
- No
- Sometimes
Short attention span
- Yes
- No
- Sometimes
Directionality
Does your child mix up or confuse rights and lefts and/or reverse letters or numbers?
- Yes
- No
- Sometimes
Does your child have any issues telling the time from a traditional clock?
- Yes
- No
- Sometimes
Does your child have any issues following dance steps or anything related to sequential movement?
- Yes
- No
- Sometimes
Visualisation
Does your child have any issues with spelling?
- Yes
- No
- Sometimes
Does your child have any issues with describing objects or scenes to you?
- Yes
- No
- Sometimes

Medical history

Please give brief answers to the following questions
Was your child conceived as a result of IVF?
When you were pregnant did you have any medical issues? (eg high blood pressure, excessive vomiting, threatened miscarriage, severe viral infection, severe emotional stress)
Did you smoke during pregnancy?
Did you have a marked viral infection in the first 13 weeks of pregnancy?
Were you under severe emotional stress at any time though in particular the first 12 weeks of your pregnancy?
Full term pregnancy, premature or late for term, please give details:
Was the birth process unusual or challenging in any way? (eg breech delivery, caesarean)
Length of labour?
When your child was born were they small for term?
Birth weight
Anything unusual about the baby when born? (eg skull distorted, heavy bruising, definitely blue, heavily jaundiced, covered with a calcium type coating or require intensive care)
In the first 13 weeks of your child’s life did they have issues sucking, have feeding problems, keeping food down or have colic?
In the first 6 months of life was your child a very still baby?
Between 6 and 18 months was your baby very active and demanding requiring minimal sleep accompanied by continual screaming?
When your child was old enough to sit up in a pram and/or stand up in the cot did they develop a marked rocking motion so that the pram or cot actually moved?
Did your child bang their head against solid objects?

Please give yes or no answers to the following questions:

Developmental history
Did your child miss out on the motor development stage of crawling on their tummy? (commando crawling)
- Yes
- No
Did your child omit going through the motor development stage of creeping on hands and knees?
- Yes
- No
Was your child a bottom shuffler?
- Yes
- No
Did they simply just one day stand up and walk?
- Yes
- No
Was there a delay in motor development?
- Yes
- No
Was your child late in learning to talk (2-3 word phrases by the age of two years)?
- Yes
- No
In the first 18 months of life did your child experience any illness involving high temperatures and/or convulsions?
- Yes
- No
Please give details of the above
Were there any signs of infant eczema/asthma or any allergic responses?
- Yes
- No
Were there any adverse reactions to childhood vaccinations?
- Yes
- No
Did your child have issues learning to dress themselves, do up buttons and tie shoelaces beyond the age of 6-7 years?
- Yes
- No
Did your child have any issues manipulating cutlery?
- Yes
- No
Did your child suck their thumb beyond the age of 5 years?
- Yes
- No
Did your child wet the bed beyond the age of 5 years?
- Yes
- No
Does your child get travel sick on a regular basis?
- Yes
- No
When your child first went to formal school (ie infant school) did they have any issues learning how to read in the first two years of school?
- Yes
- No
In the first 2 years of formal schooling did your child have any issues learning how to write?
- Yes
- No
Did your child have any issues with cursive, joined up writing?
- Yes
- No
Did your child have issues learning how to ride a bicycle?
- Yes
- No
Did your child experience frequent ear, nose and throat infections?
- Yes
- No
Does your child have issues catching a ball or at PE?
- Yes
- No
Does your child have issues sitting still for any length of time?
- Yes
- No

Nutritional information:

Has your child ever experienced any of the following on a regular basis?
Colic
- Yes
- No
Tummy pains or wind
- Yes
- No
Unusual bowel patterns
- Yes
- No
Recurrent constipation
- Yes
- No
Diarrhoea
- Yes
- No
Eczema
- Yes
- No
Dry patches on the face or arms
- Yes
- No
Nutmeg grater skin on the upper arms or thigh
- Yes
- No
Dermatitis
- Yes
- No
Mouth ulcers
- Yes
- No
Bad breath
- Yes
- No
Tonsillitis
- Yes
- No
Earache
- Yes
- No
Sinusitis
- Yes
- No
Persistent runny nose
- Yes
- No
Snoring
- Yes
- No
Mouth breathing
- Yes
- No
Hay fever
- Yes
- No
Asthma induced by exercise, infection, dust, mould, animals or food
- Yes
- No
Does your child experience excessive thirst?
- Yes
- No
Do their symptoms in general become more marked if they go more than a 2-3 hr interval without eating?
- Yes
- No
Are there any particular foods that alter their behaviour?
- Yes
- No
Auditory Processing
Has your child ever been investigated specifically for hearing difficulties?
- Yes
- No
Does your child have a short attention span?
- Yes
- No
Is your child easily distracted?
- Yes
- No
Is your child oversensitive to sounds?
- Yes
- No
Does your child confuse similar sounding words or have a frequent need for words to be repeated?
- Yes
- No
Does your child have issues following sequential instructions?
- Yes
- No
Does your child overreact to unexpected noise?
- Yes
- No
Does your child have issues following sequential instructions when issued verbally?
- Yes
- No
Does your child have a flat and monotonous voice?
- Yes
- No
Does your child have hesitant speech?
- Yes
- No
Does your child have a weak vocabulary?
- Yes
- No
Does your child have problems forming complete sentences when writing or talking?
- Yes
- No
Is your child able to sing in tune?
- Yes
- No
Is your child good at reading aloud?
- Yes
- No
Does your child have low tolerance for frustration?
- Yes
- No
Does your child have a reduced self-image?
- Yes
- No
Does your child have issues making friends?
- Yes
- No
Does your child have a tendency to withdraw or avoid others?
- Yes
- No
Does your child have good motivation?
- Yes
- No
Does your child show immaturity?
- Yes
- No
Does your child show irritability?
- Yes
- No
Does your child show shyness?
- Yes
- No

Copyright Mark Menezes

Parent Questionnaire

Step 1 of 4

Visual Symptoms

Directionality

Visualisation

Medical history

Developmental history

Nutritional information:

Auditory Processing