1.
Your Name
First name
(required)
Last name
(required)
email address
(required)
Country
(required)
2.
Age of person about whom this questionnaire is being completed
3 to under 5 years
5 to under 16 years
3.
Child's Details
Child's Name
Child's date of birth
(dd/mm/yyyy)
4.
Behavioural problems:
Select any/all categories that are appropriate to your child
At school
Restlessness or hyperactivity
At home
Resistance to going to school
Concentration problems
No Behavioural Problems
Attention difficulties ("dreamy)"
5.
Difficulties at school:
We don't have any schooling difficulties
Yes there are schooling difficulties (Please select from the list below)
Reading or beginning to read
Completing work on time
Reading comprehension
Remembering homework tasks
Spelling
Remembering instructions
Written language
Organisation
Maths
6.
Handwriting:
Select any/all categories that are appropriate to your child
Incorrect pencil grip
Letters not sitting on a line
Presses very hard when writing
Difficulty in copying from the whiteboard/book
Write letters/numbers incorrectly
Doesn’t always start at the margin
Poor spacing between words/letters
Writes very slowly
Letter confusion e.g. m – w, n - u, b - d
Can’t get ideas on paper quickly
Reversals of letters/numbers
No Handwriting difficulties
7.
Posture:
Select any/all categories that are appropriate to your child
Sits on feet
Holds head up with non writing hand
Wriggles when doing schoolwork
No Posture problems
8.
Motor skills - Problems with:
Select any/all categories that are appropriate to your child
Jumping
Tying shoe laces
Hopping
Doing up buttons/zips
Skipping
Using a knife and fork
Balancing
Hand dominance not established
Catching and throwing a ball
Right/left confusion
Cutting with scissors
No Motor Skills Problem
Thank you
for completing the questionnaire.