PARENT’S QUESTIONNAIRE

Proposed date for assessment

Student’s Full Name

Date of Birth and Age (YY/MM)

Home Address & Post Code

Parents/Guardians’ Names

Phone Nos day and evening

email address

School

STUDENT DETAILS

Do you agree to a copy of your child’s details and progress being kept on our computer to be used solely for our internal administrative purposes? (Note: Essential for assessment)
Do you agree to a photograph of your child being taken to incorporate into the report and kept on our computer, again to be used solely for our internal administrative purposes? (Note: Essential for charts and lessons)
Did your child crawl? If so, at what age and for how long?
At what age did your child talk? (or early, normal, late) walk? (or early, normal, late)
Is your child well coordinated or sometimes clumsy?
Hearing does your child have any hearing problems? when was your child’s last hearing test? Has your child had ear problems? e.g. glue ear or grommets
Sight does your child have any eye problems? when was your child’s last eyesight test? is there any indication of colour-blindness?
Were there any difficulties during pregnancy or birth, such as delayed breathing or lack of oxygen? Please give details
Has your child been absent from school for any significant length(s) of time? Please give details
Has your child suffered any family or personal trauma that may have contributed to learning difficulties? Please give details
Has your child received any or all of the following a. conventional teaching of reading and spelling? b. adequate teaching of reading and spelling? c. additional tuition for reading and spelling? Please give details
Is there any history of learning difficulties within your family, especially any brothers, father or grand-father of your child? What is the occupation of your child’s father? Please give details
What concerns you most about your child’s learning. (Enjoyment of reading; performance at spelling, maths, art, practical work; self worth etc.) Please give details.
How did you find out about us? Please give details
Signature	Date