Helping Hand Screening form

  • Helping Hand

    Screening Questionnaire
  • Format: (000) 000-0000.

  •  The INPP Screening Questionnaire

    Devised by Blythe and McGlown. © 1979, 1998. Amended Goddard Blythe 2006.

     

    Part 1 – Neurological

    Historical Infancy

  • Is there any history of learning difficulties in either parent or their families?
  • Was your child conceived as a result of IVF?
  • When you were pregnant, did you have any medical problems?e.g. High blood pressure, excessive vomiting, threatened miscarriage, severeviral infection, severe emotional stress, please state
  • Please tick all that apply
  • Was your child born approximately at term, early for term or late for term?
  • Was the birth process unusual or difficult in any way?
  • When your child was born, was he/she small for term?
  • When he/she was born, was there anything unusual abouthim/her?i.e. the skull distorted,heavy bruising, definitely blue, heavily jaundiced, covered with a calcium-typecoating or require intensive care.
  • In the first 13 weeks of your child’s life, did he/shehave difficulty in sucking, feeding problems, keeping food down or colic?
  • Was your child breast fed
  • In the first 6 months of your child’s life, was he/she a very stillbaby, so still that at times you wondered if it was a cot death?
  • Between 6 months and 18 months, was your child very active and demanding, requiring minimal sleep accompanied by continual screaming?
  • When your child was old enough to sit up in the pram and stand up in thecot, did he/she develop a violent rocking motion, so violent that either thepram or cot was actually moved?
  • Did your child become a ‘head-banger’ i.e. bang his/her headdeliberately into solid objects?
  • Was your child early (before 10 months) or late (later than 16 months)at learning to walk?
  • Did he/she omit to go through the motor developmental stage of crawling on his/her tummy? (commando crawling)
  • Did he/she omit to go through the motor development stage of creeping on hands and knees?
  • Or was your child a bottom shuffler, or simply one day stood up andwalked?
  • Was your child late at learning to talk? (2–3 word phrases by 2 years)
  • In the first 18 months of life, did your child experience any illness involving high temperatures and/or convulsions?
  • Was there any sign of infant eczema or asthma?
  • Was there any sign of other allergic responses?
  • Was there adverse reaction to any of the childhood vaccinations?
  • Did your child have difficulty learning to dress him/herself?
  • Did you child suck his/her thumb through to 5 years ormore?If so, which thumb?
  • Did your child wet the bed, albeit occasionally, above the age of 5years?
  • Does your child suffer from travel sickness?
  • When your child went to the first formal school, i.e. infant school, inthe first 2 years of schooling, did he/she have problems learning to read?
  • In the first 2 years of formal schooling did he/shehave problems learning to write?
  • Did he/she have problems learning to do ‘joined up’ or cursive writing?
  • Did he/she have difficulty learning to tell the time from a traditional clock face as opposed to a digital clock?
  • Did he/she have difficulty learning to ride a two-wheeled bicycle?
  • Was or is he/she an Ear, Nose and Throat (ENT) child, i.e. suffernumerous ear infections, is a ‘chesty’ child or suffers from sinus problems?
  • Did/does your child have difficulty in catching a ball, i.e. eye-handcoordination problems?
  • Is your child one who cannot sit still, i.e. has ‘ants-in-the-pants’ andis continually being criticized by the teachers?
  • Does your child make numerous mistakes when copying from a book?
  • When your child is writing an essay or news item at school, does he/she occasionally put letters back to front or miss letters or words out?
  • If there is a sudden, unexpected noise or movement, does your child over-react?
  • Should be Empty: