INPP Child Screening Questionnaire

Adult Screening Questionnaire

If you would like us to process your completed questionnaire please print and post to us at:
INPP Ltd, 1 Stanley Street, Chester CH1 2LR

 

Part 1

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

Part 2 Onset

What symptoms did you have?
Is there any one time or place where your symptoms are worse? If so, please explain:

 

How old were you when your problems started?
Can you go out alone?
Do you have feelings that at times you will fall over?
Do you see things moving which you know cannot move, ie. buildings, trees, etc?
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?
Do you suffer from feelings of nausea?
Do you have feelings of dizziness?
Do you have feelings of dizziness whilst lying in bed?
Do you feel that you have poor balance?
Do you feel your co-ordination is very bad at times?

Part 3

  
Do you, or have you suffered from migraine?
Are you very sensitive to bright lights, ie. at a discotheque with flashing lights?
Would you say that you are more sensitive to sound than everyone you know?
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?
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?
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?
When you are very, very tired do you find that your co-ordination goes and you bump into things or become clumsy?

Please post completed questionnaire to:

INPP Ltd, 1 Stanley Street, Chester CH1 2LR