Adult Screening Questionnaire

Part 1

Please list your presenting symptoms:
Have you received a diagnosis (or diagnoses) at any time? If so, please list:
When you started school, did you have a lot of problems learning to read? Valid Please select an option.
Did you have a lot of problems learning to write, or changing from baby writing to adult 'linked' writing? Valid Please select an option.
Did you have difficulty in learning to tell the time from a clock? Valid Please select an option.
Did you have problems in learning to ride a bicycle? Valid Please select an option.
Did you suffer from travel sickness as a child? Valid Please select an option.
At junior school, did you have difficulty in learning to catch a tennis ball? Valid Please select an option.
In the first 8 years of your life, did you have any illnesses involving very high temperature, convulsions or delirium? Valid Please select an option.
In the first 8 years of your life, were you the child who continually suffered from cold, chest infections or ear problems? Valid Please select an option.
When you were older and had to do gymnastics, did you have more trouble than all your classmates in doing things like forward rolls, handstands, climbing a rope, balancing or jumping over a vault horse? Valid Please select an option.
Around the age of puberty, did you start to suffer from regular and severe headaches? Valid Please select an option.

Part 2 - Onset

What symptoms did you have?
Is there any one time or place where your symptoms are worse? If so, please explain:
Valid Please select your age.
Can you go out alone? Valid Please select an option.
Do you have feelings that at times you will fall over? Valid Please select an option.
Do you see things moving which you know cannot move, ie. buildings, trees, etc? Valid Please select an option.
Do you ever feel that your eyes will not work properly at times, ie that they do not focus properly, or play tricks on you? Valid Please select an option.
Do you suffer from feelings of nausea? Valid Please select an option.
Do you have feelings of dizziness? Valid Please select an option.
Do you have feelings of dizziness whilst lying in bed? Valid Please select an option.
Do you feel that you have poor balance? Valid Please select an option.
Do you feel your co-ordination is very bad at times? Valid Please select an option.

Part 3

Do you, or have you suffered from migraine? Valid Please select an option.
Are you very sensitive to bright lights, ie. at a discotheque with flashing lights? Valid Please select an option.
Would you say that you are more sensitive to sound than everyone you know? Valid Please select an option.
Do you have problems in sorting out which is left and right when giving directions or sorting out which is your left and right hand? Valid Please select an option.
When you are writing a long and complicated letter, do you find that after a time you begin to make silly mistakes, such as putting letters in the wrong order, words in the wrong order, or does spelling even simple words become a problem? Valid Please select an option.
When you are very, very tired do you find that you know what you want to say but what you do say actually comes out jumbled up? Valid Please select an option.
When you are very, very tired do you find that your co-ordination goes and you bump into things or become clumsy? Valid Please select an option.

Enter the following details and a representative of INPP will contact you in due course:

Your Details

Valid Please enter your name.
Valid Required.Please enter a valid email address.
Valid Please enter your phone number (Mobile or Home).

Your Address

Valid Please enter the first line of your address.
Valid Not required
Valid Please enter your town.
Valid Please enter your county.
Valid Please enter a valid postcode, Eg: CH1 2LR.

Please only submit the questionnaire if you are resident in the UK or intend to travel to the UK for further assessment.

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