Adult Questionnaire ‹ Kinesis Consultancy

PART 1 – NEUROLOGICAL DEVELOPMENT

Is there any history of similar difficulties in your parents or their families?

Yes

Were you conceived as a result of IVF?

Yes

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

Did she drink alcohol during pregnancy?

Yes

Did she have a bad viral infection in the first 13 weeks of her pregnancy?

Yes

Was she under severe emotional stress between 25-27th week of her pregnancy?

Yes

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

Were you breast fed?

Yes

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

Between 6 months and 18 months, were you very active and demanding, requiring minimal sleep accompanied by continual screaming?

Yes

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

Did you become a ‘head-banger’ i.e. bang your head deliberately into solid objects?

Yes

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

Please give details

Were you a child late at learning to walk?

Yes

Were you a child late at learning to talk? (3 word phrases)

Yes

In the first 18 months of life, did you experience any illness involving high temperatures and/or convulsions?

Yes

Please give details

Was there any sign of infant eczema or asthma?

Yes

Was there any sign of allergic responses?

Yes

Was there adverse reaction to childhood vaccinations?

Yes

Did you have difficulty learning to dress?

Yes

Did you suck your thumb through to 5 years or more?

Yes

Which thumb?

Right

Left

Did you wet the bed, albeit occasionally, above the age of 5 years?

Yes

Did you suffer from travel sickness?

Yes

Part 2

When you started school, did you have a lot of problems learning to read?

Yes

Did you have a lot of problems learning to write, or changing from baby writing to adult 'linked' writing?

Yes

Did you have difficulty in learning to tell the time from a clock?

Yes

Did you have problems in learning to ride a bicycle?

Yes

Did you suffer from travel sickness as a child?

Yes

At junior school, did you have difficulty in learning to catch a tennis ball?

Yes

In the first 8 years of your life, did you have any illnesses involving very high temperature, convulsions or delirium?

Yes

In the first 8 years of your life, were you the child who continually suffered from cold, chest infections or ear problems?

Yes

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

Around the age of puberty, did you start to suffer from regular and severe headaches?

Yes

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

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