Name
*
First Name
Last Name
Email
*
Name of child:
*
Telephone No:
Date of birth:
*
Has a diagnosis been given at any time ie. Dyslexia, dyspraxia, ADHD, ADD? If so, please state:
*
What investigations/interventions has your child received in the past?
*
What are the presenting symptoms?
*
1. Is there any history of learning difficulties in either parent or their families?
*
Yes
No
2. Was your child conceived as a result of IVF?
*
Yes
No
a) Did you smoke during pregnancy?
*
Yes
No
b) Did you drink alcohol during pregnancy?
*
Yes
No
c) Did you have a viral infection in the first 13wks of your pregnancy?
*
Yes
No
d. Were you under severe emotional stress at any time, but particularly in the first 12wks of your pregnancy?
*
Yes
No
4. Was your child born approximately at term, early or late for term? Please give details:
*
5. Was the birth process unusual or difficult in any way? If yes, please give details: *
*
6. When your child was born was he/she small or large for term? Please give birth weight if known.
*
7. When he/she was born, was their anything unusual about him/her? i.e. the skull distorted, heavy bruising, definitely blue, heavily jaundiced, covered with calcium-type coating, or require intensive care. If yes, please give details: *
*
8. In the first 13 week of your child's life did he/she have difficultly in sucking, feeding problems, keeping food down or colic?
*
a) Was your child breast fed?
*
Yes
No
b) If yes, How long was your child breast fed for?
*
9. In the first 6 months of your child's life, was he/she a very still baby, so still that at times you wondered if it was cot death?
*
Yes
No
10. Between 6 and 18 months was your child very active and demanding, requiring minimal sleep accompanied by continual screaming?
*
Yes
No
11. When your child was old enough to sit up in the pram and stand in the cot, did he/she develop a violent rocking motion, so violent that either the pram or cot actually moved?
*
Yes
No
12. Did your child become a 'head-banger' i.e. bang his/her head deliberately into solid objects?
*
Yes
No
13. Was your child early (before 10months) or late (later than 16 months) at learning to walk?
*
Yes
No
14. Did he/she omit to go through the motor developmental stage of crawling on his/her tummy? (commando crawling)
*
Yes
No
15. a. Did he/she omit to go throught the motor development stage of creeping on hands and knees?
*
Yes
No
15b. Or was your child a bottom shuffler, or simply one day stood up and walked?
*
Yes
No
16. Was your child late to talk? (2-3 word phrases by two years)
*
Yes
No
17. In the first 18mths of life, did your child experience any illness involving high temperatures and/or convulsions? If yes, please give details:
*
Yes
No
18. Was there any sign of infant eczema or asthma?
*
Yes
No
18a. Was there any sign of other allergic responses?
*
Yes
No
19. Was there any adverse reaction to any of the childhood vaccinations?
*
Yes
No
20. Did your child have difficulty learning to dress him/herself?
*
Yes
No
21. Did your child suck his/her thumb through to 5 years or more? If so, which thumb?
*
Yes- Right
Yes- Left
No
22. Did your child wet the bed, albeit occasionally above the age of 5 years?
*
Yes
No
23. Does your child suffer from travel sickness
*
Yes
No
24. When your child went to the first formal school, i.e. infant school, in the first 2 years of schooling, did he/she have problems learning to read?
*
Yes
No
25. In the first 2 years of formal schooling did he/she have problems learning to write?
*
Yes
No
25a. Did he/she have problems learning to do 'joined up' or cursive writing?
*
Yes
No
N/A
26. Did he/she have difficulty learning to tell the time from a traditional clock face as opposed to a digital clock?
*
Yes
No
N/A
27. Did he/she have difficulty learning to ride a two-wheeled bicycle?
*
Yes
No
N/A
28. Was he/she an Ear, Nose and Throat (ENT) child, i.e. suffer from numerous ear infections, is a 'chesty' child or suffers from sinus problems?
*
Yes
No
29. Did/does your child have difficulty in catching a ball, i.e. eye-hand coordination problems?
*
Yes
No
30. Is your child one who cannot sit still, i.e. has 'ants-in-the-pants' and is continually being criticised by teachers?
*
Yes
No
31. Does your child make numerous mistakes when copying from a book?
*
Yes
No
32. When your child is writing an essay or news item at school, does he/she occasionally put letters back to front or miss letters or words out?
*
Yes
No
33. If there is a sudden, unexpected noise or movement, does your child over-react?
*
Yes
No
Please add any additional information here:
1. Gastro intestinal problems:
*
Tick all that apply
2 Skin
*
Tick all that apply
3. Ear, Nose and Throat Problems
*
Tick all that apply
4. Asthma, induced by:
*
Tick all that apply
5a. Does your child have excessive thirst?
*
Yes
No
5b. Do his/her symptoms get worse if he/she has more than a 2-3hour interval without food?
*
Yes
No
5c. Are there any particular foods which alter his/her behaviour? If yes, please specify:
*
Yes
No
Part 3 - Auditory
*
Tick all that apply
Receptive Listening -
*
This is the listening that is directed outward. It keeps us attuned to the world around us.
Do any of the following apply to your child? Tick all that apply
The Level of Energy
*
The ear acts as a dynamo, providing us with the energy we need to survive and lead fulfilling lives.
Does your child experience any of the following? Tick all that apply.
Expressive Listening
*
This is the listening that is directed within. We use it to control our voice when we speak and sing.
Please indicate if any of the following applies to your child:
Behavioural and Social Adjustment
*
A listening difficulty is often related to the following. Please indicate which (if any) apply to your child:
Star of the Sea Neurodevelopmental Therapy
*
How did you hear about us?
Please add any additional information relevant to your child's presenting problems.
Ideally the questionnaire is followed up by a discussion. Would you be happy to be contacted to arrange a convenient time for this to take place?
Yes
No
If this questionnaire should indicate that your child would potentially benefit from the INPP Method. Would you be happy to be contacted to discuss this further?
*
Yes
No
Further contact - please indicate how you would prefer to be contacted regarding this questionnaire:
*
Email
Phone
