Home
About
Testimonials
Information
Primitive Reflexes
Books and Research
Services
Neurodevelopmental Therapy
>
Online
Face-to-Face
Sound Therapy
Contact
Reflex Screener (child)
Please complete this screener for your child.
Some questions may not be applicable, depending on the age of your child. Just answer the questions that apply.
7 or more 'yes' responses gives a reliable indication of retained primitive reflexes being present.
Child Screening Questionnaire
*
Indicates required field
Parent/Carer Name
*
First
Last
Suburb
*
State/Country
*
Phone Number
*
Email
*
Child's Name
*
First
Last
Child's Date of Birth
*
Is there any history of learning difficulty in your immediate family?
*
Yes
No
Was your child conceived through IVF?
*
Yes
No
Were there any medical problems during pregnancy?
*
Yes
No
Eg high blood pressure, excessive vomiting, severe viral infection, severe emotional stress
Was the birth process stressful, traumatic, unusual, prolonged, required intervention? (caesarean, suction, forceps)
*
Yes
No
Was your child born early or late for term? (more than 2 weeks early or more than 10 days late)
*
Yes- Early
Yes- Late
No
Was your child's birth weight below 5lbs/2.2kg?
*
Yes
No
Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?
*
Yes
No
Was your child extremely demanding in the first 6 months of life?
*
Yes
No
Did your child skip the 'motor stage' of crawling on his/her tummy or creeping on hands and knees?
*
Yes
No
Was your child late at learning to walk? (16 months or later would be considered late)
*
Yes
No
Was your child late at learning to talk? (2-3 word phrases at 18 months or later would be considered late)
*
Yes
No
Did your child have difficulty learning to dress himself/herself?
*
Yes
No
Difficulty doing up buttons or tying shoe laces beyond 6-7 years of age
Does your child suffer from allergies, asthma or eczema?
*
Yes
No
Did your child have an adverse reaction to any of their vaccinations?
*
Yes
No
Did your child suck his/her thumb beyond 5 years of age?
*
Yes
No
Not 5 yet
Did your child continue to wet the bed, albeit occassionally, beyond 5 years of age?
*
Yes
No
Not 5 yet
Does your child suffer from motion/travel sickness?
*
Yes
No
Did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock?
*
Yes
No
Under 7 yrs of age still
Did your child have an unusual degree of difficulty learning to ride a bike?
*
Yes
No
Still learning
Too young to ride yet
Did your child suffer frequent ear, nose, throat or chest infections at any time in development?
*
Yes
No
In the first 3 years of life, did your child suffer any illnesses involving high temperatures, delirium or convulsion?
*
Yes
No
Does your child have difficulty catching a ball, doing forward rolls/somersaults and stand out as 'awkward' in PE classes?
*
Yes
No
Does your child have difficulty sitting still for even a short period of time?
*
Yes
No
If there is a sudden, unexpected noise does your child over-react?
*
Yes
No
Does your child have reading difficulties?
*
Yes
No
Not at school yet
Does your child have writing difficulties?
*
Yes
No
Not at school yet
Does your child have copying difficulties?
*
Yes
No
Not at school yet
Has your child had a diagnosis?
*
Yes
No
Please give details of any diagnosis
*
What are the major concerns or challenges?
*
Please give any additional information that you think might be relevant
*
How did you hear about us?
*
Friend/Relative
Social Media
Other
Submit
Home
About
Testimonials
Information
Primitive Reflexes
Books and Research
Services
Neurodevelopmental Therapy
>
Online
Face-to-Face
Sound Therapy
Contact
Reflex Screener (child)