Questionnaire - Chrysalis NDT

Parent/Guardian Name

Parent/Guardian Email

Child's Name

Child's Age

Is there any history of learning difficulties in your immediate family?

Yes
No

Were there any medical problems during the pregnancy?

Yes
No

Was the birth process unusual or prolonged in any way? e.g. C-Section, forceps, etc

Yes
No

Was your child born early or late for term (more than 2 weeks early or more than 10 days late)?

Yes
No

Was your child's birth weight below 5 lbs (pounds)?

Yes
No

Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?

Yes
No

Was your child extremely demanding in the first 6 months of life?

Yes
No

Did your child miss out/skip the 'motor stage' of crawling on his or her tummy and creeping on hands and knees?

Yes
No

Did 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?

Yes
No

Does your child suffer from allergies?

Yes
No

Was your child late at learning to walk (16 months or later would be considered late)?

Yes
No

Did your child have an adverse reaction to any of his or her vaccinations?

Yes
No

Did your child suck his or her thumb beyond the age of 5 years?

Yes
No

Did your child continue to wet the bed, albeit occasionally, above the age of 5 years?

Yes
No

Does your child suffer from travel sickness/motion sickness?

Yes
No

Did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock?

Yes
No

Did your child have an unusual degree of difficulty learning to ride a bicycle?

Yes
No

Did your child suffer from frequent ear, nose, throat or chest infections at any time in development?

Yes
No

In the first 3 years of life, did your child suffer form any illnesses involving extremely high temperatures, delirium or convulsion?

Yes
No

Does your child have difficulty catching a ball, doing forward rolls/ somersaults and stand out as 'awkward' in PE classes?

Yes
No

Does your child have difficulty sitting still for even a short period of time?

Yes
No

If there is a sudden unexpected noise, does your child over-react?

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

Has your child had a diagnosis?

Yes
No

Any additional Information or concerns about your child?