Pre Assessment Questionnaire

Patient's Full Name*

Email Address*

Home Address*

Postcode*

Home Telephone Number

Patient's Daytime Number*

Date of Birth*

School

Who referred you to our practice?

Name and Address of G.P

General Signs

Difficulty with co-ordination*

Yes
No

Problems with balance*

Yes
No

Prone to travel sickness*

Yes
No

Untidy handwriting*

Yes
No

Discomfort in hand when writing*

Yes
No

Letters formed backwards in writing*

Yes
No

Difficulties with spelling*

Yes
No

Development History

Were there any complications during pregnancy, or at birth? (please give details)*

Was birth premature?*

Yes
No

Did Birth Involve:

Caesarian Section?*

Yes
No

Forceps?*

Yes
No

Was birth weight low?*

Yes
No

Did child thrive?*

Yes
No

Jaundice?*

Yes
No

At what age did your child:

Crawl?*

Was crawling normal?*

Yes
No

Walk?*

Talk?*

Was speech therapy needed?*

Yes
No

Is speech now clear?*

Yes
No

Hearing

Have there been any hearing problems?*

Yes
No

Please detail, including which ear was involved (if known)*

Have grommets been used?*

Yes
No

Is hearing now reported to be normal?*

Yes
No

Does child respond well to verbal instructions?*

Yes
No

Health

Does your child have any health problems?*

Yes
No

Please give details*

Does your child suffer from allergies?*

Yes
No

Please give details*

Does your child have any nutritional or eating problems?*

Yes
No

Please give details*

Family History

Is there any family history of visual problems?*

Yes
No

Please give details*

Is there any family history of dyslexia or learning difficulty?*

Yes
No

Please give details*

Is there any family history of hyperactivity, attention difficulties or speech problems?*

Yes
No

Please give details*

Laterality

Is your child?*

Left Handed
Right Handed
Ambidextrous

Hand dominance in family (indicate Left, Right or Ambidextrous)

Father*

Mother*

Siblings

1.*

2.

3.

4.

Does child confuse directions and lefts and rights?*

Yes
No

Is there similar confusion in the family?

Maternal Side?*

Yes
No

Paternal Side?*

Yes
No

School

Have your child’s school expressed any concerns about academic progress?*

Yes
No

Is your child receiving extra support either in or out of school?*

Yes
No

Does your child experience difficulties in other subjects apart from English?*

Yes
No

Please give Details*

Have there been any behavioral problems?*

Yes
No

Please give Details*

Have any other tests been carried out (e.g. educational psychological evaluation)*

Yes
No

Upload copy of any reports that have been prepared*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

In your opinion, what are your child’s:

Best Subjects?*

Worst Subjects?*

What are your child’s special interests and hobbies?*

Does your child enjoy school?*

Yes
No

Are you satisfied with child’s school performance?*

Yes
No

Does child read as well as peer group in school?*

Yes
No

Does child read as well as brothers and sisters?*

Yes
No

Checklist

Appearance of eyes*

One eye appears to turn in or out at times
Reddened eyes or lids
Eyes tear excessively

Complaints when using eyes at desk*

Headaches
Burning or itchy eyes after reading or deskwork
Print blurs after reading for a while
Complains of seeing double
Words ‘swim’ or move on the page

Behavioral signs of visual problems

Eye movements*

Moves head a lot when reading
Loses place frequently when reading
Needs to use finger or marker to keep place
Rereads or skips lines
Short attention span when reading
Omits words

Eye teaming*

Repeats letters within words
Omits letters numbers or phrases
Misaligns digits in columns
Squints, closes or covers one eye
Tilts head a lot when working at desk
Odd working posture at desk activities

Eye-hand coordination*

Has to feel things ‘to get an idea’
Writes crookedly, poorly spaced; cannot stay on ruled lines
Misaligns both horizontal and vertical lines of numbers
Discomfort in hand when writing
Repeatedly confuses left –right directions
Has difficulty with ball activities

Visual form perception*

Auditory difficulties*

Often asks you to repeat things
Daydreams a lot in class
Easily distracted by background noises
Cannot work in silent conditions
Unclear speech

Are there any other factors, or further information you feel would be of help to us?

Relation to Child*

It is often beneficial to discuss examination results with other professionals working with your child; authorise this exchange of information by checking this field.*

I Authorise the exchange of information

Assessment Form

General Signs

Development History

Did Birth Involve:

At what age did your child:

Hearing

Health

Family History

Laterality

Hand dominance in family (indicate Left, Right or Ambidextrous)

Siblings

Is there similar confusion in the family?

School

In your opinion, what are your child’s:

Checklist

Behavioral signs of visual problems

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