Helping Hand Screening form

Name

First NameLast Name

Parent or guardian if relevant

Email

example@example.com

Phone Number

Please enter a valid phone number.

Has a diagnosis been given at any time i.e. Dyslexia, Dyspraxia, ADHD or ADD?If so, please state.

Is your child currently taking any prescribed medication? Please Specify.

What investigations/interventions has your child received in the past?

What are the presenting symptoms?

The INPP Screening Questionnaire

Part 1 – Neurological

Historical Infancy

Is there any history of learning difficulties in either parent or their families?

YesNoI don't know

Was your child conceived as a result of IVF?

YesNoI don't know

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

YesNoI don't know

Please tick all that apply

Did you smoke during pregnancy?Did you drink alcohol during pregnancy?Did you have a bad viral infection in the first 13 weeks of your pregnancyWere you under severe emotional stress at any time, but particularly in the first 12 weeks of your pregnancy

Was your child born approximately at term, early for term or late for term?

YesNoI don't know

Was the birth process unusual or difficult in any way?

YesNoI don't know

When your child was born, was he/she small for term?

YesNoI don't know

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.

YesNoI don't know

In the first 13 weeks of your child’s life, did he/shehave difficulty in sucking, feeding problems, keeping food down or colic?

YesNoI don't know

Was your child breast fed

YesNoI don't know

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?

YesNoI don't know

Between 6 months and 18 months, was your child very active and demanding, requiring minimal sleep accompanied by continual screaming?

YesNoI don't know

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?

YesNoI don't know

Did your child become a ‘head-banger’ i.e. bang his/her headdeliberately into solid objects?

YesNoI don't know

Was your child early (before 10 months) or late (later than 16 months)at learning to walk?

YesNoI don't know

Did he/she omit to go through the motor developmental stage of crawling on his/her tummy? (commando crawling)

YesNoI don't know

Did he/she omit to go through the motor development stage of creeping on hands and knees?

YesNoI don't know

Or was your child a bottom shuffler, or simply one day stood up andwalked?

YesNoI don't know

Was your child late at learning to talk? (2–3 word phrases by 2 years)

YesNoI don't know

In the first 18 months of life, did your child experience any illness involving high temperatures and/or convulsions?

YesNoI don't know

Was there any sign of infant eczema or asthma?

YesNoI don't know

Was there any sign of other allergic responses?

YesNoI don't know

Was there adverse reaction to any of the childhood vaccinations?

YesNoI don't know

Did your child have difficulty learning to dress him/herself?

YesNoI don't know

Did you child suck his/her thumb through to 5 years ormore?If so, which thumb?

YesNoI don't know

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

YesNoI don't know

Does your child suffer from travel sickness?

YesNoI don't know

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?

YesNoI don't know

In the first 2 years of formal schooling did he/shehave problems learning to write?

YesNoI don't know

Did he/she have problems learning to do ‘joined up’ or cursive writing?

YesNoI don't know

Did he/she have difficulty learning to tell the time from a traditional clock face as opposed to a digital clock?

YesNoI don't know

Did he/she have difficulty learning to ride a two-wheeled bicycle?

YesNoI don't know

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?

YesNoI don't know

Did/does your child have difficulty in catching a ball, i.e. eye-handcoordination problems?

YesNoI don't know

Is your child one who cannot sit still, i.e. has ‘ants-in-the-pants’ andis continually being criticized by the teachers?

YesNoI don't know

Does your child make numerous mistakes when copying from a book?

YesNoI don't know

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?

YesNoI don't know

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

YesNoI don't know