IS THAT MY CHILD - QUESTIONNAIRE
The following questionnaire it to help you consider possible factors you may
need to be aware of about your child. These answers may provide clues as to
what is wrong with your child, if anything, but it should only be used as a
rough guide and is not a replacement for a proper diagnosis. Simply answer
the questions, add up the points and read the result below.
1. Is there a family history of any learning or behavioral problems?
Yes = 10 points, No = 0 points
2. Were you and the baby fit and well during the pregnancy?
Yes = 0 points, No = 1 point
3. Did the pregnancy go to full term?
Yes = 0 points, No = 2 points
4. Was the delivery natural or assisted (ventouse, Caesarean or forceps)?
Natural = 0 points, Assisted = 5 points
5. Was there any concern over fetal distress?
Yes = 5 points, No = 0 points
6. When did your child sit unaided?
Six months or earlier = 0 points, Later than six months = 2 points
7. Did your child crawl?
Yes = 0 points, No = 2 points
8. When did your chld walk?
One year or earlier = 0 points, Later than one year = 1 point
9. In the first year did your child have a collection of single words?
Yes = 0 points, No = 1 point
10. In the second year did your child put two words together?
Yes = 0 points, No = 1 point
11. By the third year was your child making mini-sentences?
Yes = 0 points, No = 1 point
12. When was your child potty-trained by day?
Two and a half years or earlier = 0 points, Later than two and a half
years = 1 point
13. When was your child no longer wetting the bed at night?
Three years or earlier = 0 points, Later than three years = 2 points
14. Have there been any bed-wetting incidents since?
Yes = 1 point, No = 0 points
15. Has your child ever soiled?
Yes = 2 points, No = 0 points
16. Does your child have problems with reading/writing?
Yes = 2 points, No = 0 points
17. Does your child have problems in concentrating?
Yes = 1 point, No = 0 points
18. Is your child ever hyperactive?
Yes = 2 points, No = 0 points
19. How is your child's short term memory?
Good = 0 points, Poor = 1 point
20. Has your child ever had any rituals or obsessions?
Yes = 3 points, No = 0 points
21. Has your child ever had any involuntary movements,tics,
excessive blinking, grimacing, or made repeated sounds?
Yes = 5 points, No = 0 points
22. Is your child, or was your child ever, clumsy or accident prone?
Yes = 2 points, No = 0 points
Results:
15 points or less means that you have very little to worry about
16-29 points means that there is a high probability of developmental delay
30 points or more means that a developmental delay is virtually certain
Survey taken from the book, "The Learning Disability Myth", by Dr. Robin
Pauc.
