• Babies/Children Under 5 Questionnaire

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  • Part 1 - Neurological

    Historical Infancy

  • Numbered Questions:

    Select Yes or No and provide as much information as possible.

  • 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 alcohol 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 weeks 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 distorted, heavy bruising, defintiely 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 you 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 the 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 temperature 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 difficulty learning to dress themselves, and/or especially after any illness?
  • 20. Did your child suck their thumb through to 5 years or more? If so, which thumb, left or right?
  • 21. Does your child suffer from travel sickness?

  • SENSORY

  • 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:

  • How did you hear of The Movement & Learning Connection? Please mark as appropriate:

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  • Should be Empty: