Hong Kong Mums Screening Form

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KidsCanSucceed Training and Assessment Institute U.K.

SCREENING FORM

Childs Name: Form Completed By: Contact e-mail:

Date of Birth

Were there any medical problems during the pregnancy? Was the birth process unusual or prolonged in any way? Was your child born more than 2 weeks early or more than 10 days late? Was your child extremely demanding in the first 6 months of life? Did your child miss out the 'motor stage' of crawling on his or her tummy and creeping on hands and knees? Did they or do they W sit? Were they late to talk or walk? Does your child still wet the bed (even occasionally) over the age of 5 years? Is your child impulsive and has difficulties in sitting still, even for a short time? Are they forgetful and cant follow instructions? Do they often have ear infections, chest infections or allergies? Are they experiencing any problems with reading, writing or maths? Do they have difficulty making and keeping friends?

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