Cellfield Preliminary Assessment Questionnaire

Please note that all fields marked with ' * ' are required !

Personal Information Parent Name • *  Child Name • *    Age •   Date of Birth • dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 mm 01 02 03 04 05 06 07 08 09 10 11 12 Address • Postcode • Email • *  Telephone • (H)     (W)      (Cell)      (Fax)   Primary School grade 01 02 03 04 05 06 07        High School grade 08 09 10 11 12        Adult Background Does your child have siblings ?   Yes       No If Yes, please list ages of other children :   Did your child reach development milestones at the appropriate ages ?   Yes       No If No, please describe :   Medical History Has your child had any of the following ? Middle ear infection ('glue ear') Insertion of 'grommets' Tonsillitis or frequent sore throats Hearing problems Problems with vision (eg. blurred vision, watery eyes, bothered by glare) Headaches Convulsions Epilepsy Serious injuries. Please specify:    Other medical conditions or complaints. Please specify:    Does your child take medication ?   Yes       No If Yes, please specify name(s) of medication(s):   Has your child had his/her hearing tested ?   Yes       No Has your child had his/her eyesight tested ?   Yes       No Family History Has anyone in your child's immediate or extended family had difficulties with :   Articulation   Language skills   Stuttering   Dyslexia   Reading or Learning Has your child ever received special education help? eg. special reading group, language support classes   Yes       No

In your opinion, what is your child's current achievement at school in the following areas : Please make your selection Above Average Average Below Average Reading accuracy Reading comprehension Spelling Written expression Oral (verbal) expression Handwriting Mathematics Do any of the following apply to your child ?   Dislikes school   Blames teacher for difficulties   Complains school is boring   Refuses to cooperate with teachers   Teachers report 'discipline' problems   Is not motivated to complete class or homework activities   Frequently hands in 'sloppy' work or neglects to hand in assignments Comprehension Does your child have difficulties :   Understanding questions   Following instructions correctly   Understanding indirect requests and sarcastic comments   Following stories as a whole, drawing conclusions, making predictions   Understanding that the meaning of a word can change depending on the context Auditory Processing   Have difficulties saying speech sounds (eg. 'lellow' for 'yellow', 'fum' for 'thumb')   Have difficulties saying words of several syllables ('hostipal' for 'hospital', 'puter' for 'computer')   Fail to understand rhymes   Confuse similar-sounding words (eg. 'cone' for 'comb')   Have difficulties identifying the number of syllables or sounds in words Behaviour Activity level. Please tick the behaviours that refer to your child :   Cannot keep still or stay quiet, ' hyperactive', restless   Lethargic, often tired, fatiques quickly Attention. Please tick the behaviours that refer to your child :   Cannot concentrate on a task for long   Needs to be called back to task continually   Cannot ignore 'distractions' ; overly aware of nearby sounds, sights and smells Movement and Balance . Please tick the behaviours that refer to your child :   Poor balance on play equipment   Difficulties climbing or descending stairs   Seems overly sensitive to movement; becomes carsick regularly   Constantly moving; often swinging, twirling, bouncing and rocking Visual Perception . Please tick the behaviours that refer to your child :   Difficulties matching colours, shapes and sizes   Difficulties completing puzzles, uses 'trial and error' to place pieces   Reverses words, letters or numbers after Year One   Skips words, phrases or lines when reading   Loses place when reading or copying ; needs finger or marker to keep place   Difficulties with smoothe eye-tracking (following objects with eyes) Is there any other information relevant to your child's difficulties that you would like to tell us about ?

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Suite 392 Postnet X09, Weltevreden Park Roodepoort 1715

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