Questionnaire for Children and Students new to our clinic

The information given in this questionnaire is confidential. Please answer as many questions as possible, as this information will assist us in helping you or your child. If you do not know the answers to any of the following questions, they can be discussed during your appointment.

Child's present area of difficulty

Family History

Brothers and Sisters

Birth History

Motor Skills

Post Natal History

Developmental History


Hearing and Speech

General Development

Medical History


Any of the following?


Disorders of

Nutrition & Diet


Please list any specialists/consultants seen Eg. vision, auditory, occupational therapist, speech pathologist

Visual History