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Kinesis Consultancy Introduction
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Adult Questionnaire
PART 1 – NEUROLOGICAL DEVELOPMENT
Is there any history of similar difficulties in your parents or their families?
Yes
No
Were you conceived as a result of IVF?
Yes
No
When your mother was pregnant with you, did she have any medical problems? e.g. High blood pressure, excessive vomiting, threatened miscarriage, severe viral infection, severe emotional stress; please state
Did she smoke during pregnancy?
Yes
No
Did she drink alcohol during pregnancy?
Yes
No
Did she have a bad viral infection in the first 13 weeks of her pregnancy?
Yes
No
Was she under severe emotional stress between 25-27th week of her pregnancy?
Yes
No
If known, how many ultra-sound scans were performed?
Were you born approximately at term, early for term or late for term? Please give details
Was the birth process unusual or difficult in any way?
Prolonged labour
Precipitate (fast) labour
Forceps
Ventouse
Caesarean Section (elective or emergency)
Induced
If Induced or Caesarean, please give details
When you were born, were you small for term? Please give birth weight, if known
When you were born, was there anything unusual about you? i.e. the skull distorted, heavy bruising, definitely blue, heavily jaundiced, covered with a calcium-type coating or require intensive care. If yes, please give details
In the first 13 weeks of your life, did you have difficulty in sucking, feeding or keeping food down?
Yes
No
Were you breast fed?
Yes
No
How long did breast feeding continue?
In the first 6 months of your life, were you a very still baby, so still that at times your mother wondered if it was a cot death?
Yes
No
Between 6 months and 18 months, were you very active and demanding, requiring minimal sleep accompanied by continual screaming?
Yes
No
When you were old enough to sit up in the pram and stand up in the cot, did you develop a violent rocking motion, so violent that either the pram or cot was actually moved?
Yes
No
Did you become a ‘head-banger’ i.e. bang your head deliberately into solid objects?
Yes
No
Did you go through a motor stage of crawling on the stomach, and creeping on the hands and knees or were you a ‘bottom-hopper’ or ‘roller’ who one day stood up?
Yes
No
Please give details
Were you a child late at learning to walk?
Yes
No
Were you a child late at learning to talk? (3 word phrases)
Yes
No
In the first 18 months of life, did you experience any illness involving high temperatures and/or convulsions?
Yes
No
Please give details
Was there any sign of infant eczema or asthma?
Yes
No
Was there any sign of allergic responses?
Yes
No
Was there adverse reaction to childhood vaccinations?
Yes
No
Did you have difficulty learning to dress?
Yes
No
Did you suck your thumb through to 5 years or more?
Yes
No
Which thumb?
Right
Left
Did you wet the bed, albeit occasionally, above the age of 5 years?
Yes
No
Did you suffer from travel sickness?
Yes
No
Part 2
When you started school, did you have a lot of problems learning to read?
Yes
No
Did you have a lot of problems learning to write, or changing from baby writing to adult 'linked' writing?
Yes
No
Did you have difficulty in learning to tell the time from a clock?
Yes
No
Did you have problems in learning to ride a bicycle?
Yes
No
Did you suffer from travel sickness as a child?
Yes
No
At junior school, did you have difficulty in learning to catch a tennis ball?
Yes
No
In the first 8 years of your life, did you have any illnesses involving very high temperature, convulsions or delirium?
Yes
No
In the first 8 years of your life, were you the child who continually suffered from cold, chest infections or ear problems?
Yes
No
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?
Yes
No
Around the age of puberty, did you start to suffer from regular and severe headaches?
Yes
No
Part 3 - 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?
Yes
No
Do you have feelings that at times you will fall over?
Never
Sometimes
Often
Do you see things moving which you know cannot move, i.e. buildings, trees, etc?
Never
Sometimes
Often
Do you ever feel that your eyes will not work properly at times, i.e. that they do not focus properly, or play tricks on you?
Never
Sometimes
Often
Do you suffer from feelings of nausea?
Never
Sometimes
Often
Do you have feelings of dizziness?
Never
Sometimes
Often
Do you have feelings of dizziness whilst lying in bed?
Never
Sometimes
Often
Do you feel that you have poor balance?
Never
Sometimes
Often
Do you feel your co-ordination is very bad at times?
Never
Sometimes
Often
Part 4
Do you, or have you suffered from migraine?
Never
Sometimes
Often
Are you very sensitive to bright lights, i.e. at a discotheque with flashing lights?
Never
Sometimes
Often
Would you say that you are more sensitive to sound than everyone you know?
Never
Sometimes
Often
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?
Never
Sometimes
Often
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?
Never
Sometimes
Often
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?
Never
Sometimes
Often
When you are very, very tired do you find that your co-ordination goes and you bump into things or become clumsy?
Never
Sometimes
Often
Your Details
Enter the following details and a representative of The Kinesis Consultancy will contact you in due course:
Your Name
*
Email Address
*
Your Phone Number
*
Your Address
*
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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