QUESTIONNAIRE -Tick where appropriate and Submit completed questionnaire at the bottom of this page.

Your Name:
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Details of Case.
1. Were there any medical problems during pregnancy such as threatened miscarriage, high blood pressure, or excessive morning sickness?:	YES
2. Was the baby more than 2 weeks early or 2 weeks late?	YES
3. Were there any complications during the birth such as prolonged labour, foetal distress, forceps delivery, or Caesarian section?	YES
4. Is there any history of learning difficulties in either parents' family?	YES
5. Did the person crawl on his/her stomach, or creep on his/her hands and knees ?	YES
Did the person, as a child:
6. Find it difficult to tie shoelaces or do up buttons?	YES
7. Have reading difficulties?	YES
8. Occasionally reverse letters when writing?	YES
9. Have difficulty writing or very untidy writing?	YES
10. Find it hard to catch a ball?	YES
11. Seem awkward in P.E.?	YES
12. Have difficulty learning to ride a bicycle?	YES
13. Suffer from travel sickness?	YES
14. Find it difficult to tell left from right?	YES
15. Have a problem telling the time from a traditional clock face?	YES
16. Find it hard to sit still and pay attention?	YES
17. Had frequent ear, nose, and throat infections? frequent colds or chest problems?	YES
18. Suffer from asthma, hay fever, or allergies?	YES
19. Date	Date