Family Questionnaire

For completion by parent or guardian

If you would like any help in completing this form, please contact the Centre.

It is important that this questionnaire is completed as fully as possible; this will enable us to support your child in the most effective way.  The information given is entirely confidential to Centre staff and other professionals directly concerned with your child.

Please be aware that it may not always be possible for a formal diagnosis of a specific learning difficulty to be made as the result of an assessment.

Date of Birth *
Parents’/Guardians’ details for correspondence
Address
Order
Family Background

No family members added yet. Select a family member type and press the button below to add one.

Order
Order
Health
If possible, please state at approximately what age your child did the following
Did your child show clear preference for one hand?(Left or Right hand)
Speech, Language and Communication Development
Does/did your child have problems with
Please enclose the report(s)
More information
  • Files must be less than 80 MB.
  • Allowed file types: txt doc docx jpeg png pdf zip.
Medical History: Information about your child’s health is important.

Please tick/highlight if your child has had any of the following:

Have you noticed, or has your child ever mentioned, any visual difficulties when reading and writing such as words moving on the page, words blurring? Or other?
Activity/Behaviour: Please tick if your child has ever had difficulty with.

To book an appointment, please call 01-6327387 and 09025446486 or mail screening@dyslexianigeria.com

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30B2, Remi Fani-Kayode Street, GRA , Ikeja, Lagos, Nigeria.

+234 1 632 7387

info@dyslexianigeria.com

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