• Children's Questionnaire

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  • The INPP Screening Questionnaire

    Devised by Blythe and McGlown © 1979, 1998. Amended Goddard Blythe 2006.

  • Part 1 - Neurological

    Historical Infancy

  • Numbered Questions:

    Please mark Yes or No and provide as much information as you can.

  • 1. Is there any history of learning difficulties in either parent or their families?
  • 2. Was your child conceived as a result of IVF?
  • 3. When you were pregnant, did you have any medical problems? eg. high blood pressure, excessive vomiting, threatened miscarriage, severe viral infection, severe emotional stress, please state below.
  • a. Did you smoke during pregnancy?
  • b. Did you drink during pregnancy?
  • c. Did you have a bad viral infection in the first 13 weeks of your pregnancy?
  • d. Were you under severe emotional stress between 25-27th week of your pregnancy?
  • 5. Was the birth process unusual or difficult in any way? If yes, please give details:
  • 6. When your child was born, were they small for term? Please give birth weight if known.
  • 7. When they were born, was there anything unusual about them? ie. the skull is distorted, heavy bruising, definitely blue, heavily jaundiced, covered with a calcium-type coating or require intensive care. If yes, please give details:
  • 8. In the first 13 weeks of your child's life, did they have difficulty in sucking, feeding problems, keeping food down or colic?
  • a. Was your child breast fed? If yes, please give details on length of time they were breast fed for.
  • 9. In the first 6 months of your child's life, were they a very still baby, so still that at times you wondered if it was a cot death?
  • 10. Between 6 months and 18 months was your child very active and demanding, requiring minimal sleep accompanied by continual screaming?
  • 11. When your child was old enough to sit up in the pram and stand up in the cot, did they develop a violent rocking motion, so violent that either the pram or cot was actually moved?
  • 12. Did your child become a "head-banger" ie. bang their head deliberately into solid objects?
  • 13. Was your child early (before 10 months) or late (later than 16 months) at learning to walk?
  • 14 a. Did they go through a motor stage of crawling on the stomach?
  • 14 b. Did they creep on their hands and knees?
  • 14 c. Or did they "bottom-hop" or a "roller" who one day stood up?
  • 15. Was your child late at learning to talk? (2-3 word phrases by 2 years)
  • 16. In the first 18 months of life, did your child experience any illness involving high temperatures and/or convulsions? If yes, please give details.
  • 17 a. Was there any sign of infant eczema or asthma?
  • 17 b. Was there any sign of allergic responses?
  • 18. Was there adverse reaction to any of the childhood vaccinations?
  • 19. Did your child have difficultly learning to dress themselves, and/or especially after any illness?
  • 20. Did you child suck their thumb through to 5 years or more? (If so, which thumb - left or right)
  • 21. Did your child wet the bed, albeit occasionally, above the age of 5 years?
  • 22. Does your child suffer from travel sickness?

  • SENSORY

  • SCHOOLING

  • 26. When your child went to the first formal school, ie. infant school, in the first 2 years of schooling, did they have problems learning to read?
  • 27 a. In the first 2 years of formal schooling did they have problems learning to write?
  • 27 b. Did they have problems learning to do "joined up" or cursive writing?
  • 28. Did they have difficulty learning to tell the time from a traditional clock face as opposed to a digital clock?
  • 29. Did they have difficulty learning to ride a two-wheeled bicycle?
  • 30. Were or are they an Ear, Nose and Throat (ENT) child, ie. suffer numerous ear infections, is a 'chesty' child or suffer from sinus problems?
  • 31. Did/does your child have difficulty in catching a ball, ie. eye-hand coordination problems?
  • 32. Is your child one who cannot sit still, ie. has 'ants-in-the-pants' and is continually being criticized by the teachers?
  • 33. Does your child make numerous mistakes when copying from a book?
  • 34. When your child is writing an essay or news item at school, do they occasionally put letters back to front or miss letters or words out?
  • 35. If there is a sudden, unexpected noise or movement, does your child over-react?

  • Part 2 - Nutritional

  • Has your child suffered from any of the following at regular intervals?

    Mark all that apply.

  • 1. Gastro intestinal problems
  • 2. Skin problems

  • 3. Ear, Nose and Throat problems
  • 4. Asthma, induced by:

  • 5 a. Does your child suffer from excessive thirst?
  • 5 b. Do their symptoms get worse if they have more than a 2-3 hour interval without eating?
  • 5 c. Are there any particular foods which alter their behaviour? If yes, please specify.

  • Part 3 - Auditory

     

    Developmental History

  • 1. Was there a delay in motor development?
  • 2. Was there a delay in language development?
  • 3. Did your child suffer from recurring ear infections?
  • 4. Has your child ever been investigated specifically for hearing difficulties?

  • 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? Mark 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.

  • Do any of the following apply to your child? Mark 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.

  • Do any of the following apply to your child? Mark all that apply.

  • Behavioural and Social Adjustment

    A listening difficulty is often related to these.

  • Do any of the following apply to your child? Mark all that apply.
  • How did you hear of The Movement & Learning Connection? Please mark as appropriate.

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