1. Personal Details

Your child's name

Email Address

Home Address

Post Code

Home Phone Number

Mobile Number

Information about your family

Mother's occupation

Father's occupation

How many brothers in the family?

How many sisters in the family?

Position in the family? (1st, 2nd, 3rd child etc)

Age of brothers

Age of sisters

How does your child get on with brothers / sisters?

2. Medical Details

Does your child have eyesight problems? If yes please give details.

Does your child have hearing problems? If yes please give details.

Does your child have any other health conditions or disabilities? If yes please give details.

Has your child ever had any serious illnesses affecting attendance at school? If yes, please give details.

Does your child have asthma?

Does your child have allergies? If yes, please give details.

Is your child in receipt of any relevant medication of note? If yes, please give details.

3. Birth Details

Were there any problems during pregnancy?

If yes, please give details.

Were there any complications with your child's birth?

If yes, please give details.

Were there any complications in the early years of your child's life?

If yes, please give details.

Was the pregnancy?

What was your child's birth weight?

4. Early Development Details

Can you remember if your child started sitting up at the appropriate age?

Can you remember if your child started crawling at the appropriate age?

Can you remember if your child walked at the appropriate age?

Can you remember if your child talked at the appropriate time?

If your child had late language development, was it later than their brothers or sisters?

Was your child accident prone or clumsy?

Has your child experienced any problems with their hearing / ears?

Does your child have any speech problems? (Now or in the past)

Has your child been seen by a Speech & Language Therapist?

Have you noticed any word finding difficulties?

Do you find you have to explain the point in jokes to your child?

5. School Experiences

Age when starting primary school? (Years / months)

What hand does your child use to write?

Does your child have good attendance at school?

Please give any important information about absences.

Does your child enjoy going to school?

Please give details.

Does your child feel s/he is a good learner and doing well at school?

Is your child organised for school? (Correct books, PE kit, equipment)

Does your child have 'good and bad' days for no apparent reason?

Does your child have any difficulties with remembering and following instructions?

Does your child complete homework in the recommended time? (20-30 minutes)

Does your child get confused with left and right?

6. Educational Experiences

Does your child have difficulties with reading?

Does your child have difficulties with spelling?

Does your child have difficulties with writing?

Does your child have difficulties with maths?

Does your child have difficulties with telling time?

Does your child have difficulties with times tables?

Does your child have difficulties with days of the week?

Does your child have difficulties with seasons of the year?

Does your child have difficulties with sequencing letters of the alphabet?

Does your child have difficulties with months of the year?

Does your child have difficulties with following instructions?

Does your child have difficulties with retelling a story / event?

Who completed the diagnosis?

Will a copy of the report be shared?

Does your child receive extra help at school? If yes, please describe.

7. Friendships and Hobbies

Does your child have many friends?

What is your child's relationships with their school friends like?

1 is poor, 5 is very good.

What is your child's relationships with teachers like?

1 is Poor, 5 is very good.

If your child has a classroom assistant or support person, what is their relationship like?

1 is Poor, 5 is Very good

What is your child's favourite subject at school?

What is your child's least favourite subject at school?

What are your child's hobbies?

8. Parental views

What are your main concerns?

What would you like to happen now?

Is there anything else you would like us to know?