| CHILD IDENTIFICATION DATA | FAMILY IDENTIFICATION DATA | ||||
| 1 | Gender |
| 12 | Relationship of the person responding the questionnaire |
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| 2 | Age |
| 13 | Father | Age |
| 3 | Laterality |
| Laterality | ||
| 4 | Administrative kind of School |
| Scholarship | ||
| 5 | Language kind of school |
| 14 | Mother | Age |
| 6 | School grade |
| Laterality | ||
| 7 | Developmental history |
| Scholarship | ||
| 8 | Reason for consultation | Learning problems | 15 | Parental civil status |
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| Hyperactivity | 16 | Family structure |
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| Disperse attention | 17 | Hereditary health history |
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| Disability | 18 | Mother’s pregnancy conditions |
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| Neurological disorders | 19 | Caesarean reason (just in case) |
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| 9 | R. H. factor |
| 20 | School performance | Reading |
| 10 | Blood type |
| Writing | ||
| 11 | Health condition |
| Mathematics | ||
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| Language | ||
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| 21 | Final diagnosis |
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