Adult Screening Questionnaire
Name
First Name
Last Name
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
What are your current presenting problems?
What are you most wanting to see changes in?
Part 1
1. When you started school, did you have a lot of problems learning to read?
Yes
No
2. Did you have a lot of problems learning to write, or changing from baby writing to adult linked writing?
Yes
No
3. Did you have difficulty in learning to tell the time from a clock?
Yes
No
4. Did you have problems in learning to ride a two-wheeled bicycle?
Yes
No
5. Did you suffer from travel sickness as a child?
Yes
No
6. When you were at primary school, did you have difficulty in learning to catch a tennie ball?
Yes
No
7. In the first eight years of your life, did you have any illnesses involving very high temperature, convulsions or delirium? If yes, please explain what illnesses you had and how old you were:
8. In the first eight years of your life, were you the child who continually suffered from colds, chest infections or ear problems?
Yes
No
9. 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
10. Around the age of puberty, did you start to suffer from regular and severe headaches?
Yes
No
Part 2 - Onset
11. How old were you when your problems started?
12. What symptoms did you have?
13. Is there any one time or place where your symptoms are worse? If yes, when or when?
14. Can you go out alone?
Often
Sometimes
Never
15. Do you have feelings that at times you will fall over?
Often
Sometimes
Never
16. Do you see things moving which you know cannot move, ie. buildings, trees, etc?
Often
Sometimes
Never
17. Do you ever feel that your eyes will no work properly at times, ie. that they do not focus properly, or play tricks on you?
Often
Sometimes
Never
18. Do you suffer from feelings of nausea?
Often
Sometimes
Never
19. Do you have feelings of dizziness?
Often
Sometimes
Never
20. Do you have feelings of dizziness whilst lying in bed?
Often
Sometimes
Never
21. Do you feel that you have poor balance?
Yes
No
22. Do you feel your coordination is very bad at times?
Yes
No
Part 3
23. Do you, or have you, suffered from migraines?
Often
Sometimes
Never
24. Are you very sensitive to bright lights? (Have you been to a discotheque with flashing lights and does this affect you?)
Yes
No
25. Would you say that you are more sensitive to sound than everyone you know?
Yes
No
26. 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?
Yes
No
27. 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 your ability to spell even simple words becomes difficult?
Yes
No
28. 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?
Often
Sometimes
Never
29. When you are very, very tired, do you find that your coordination goes and you bump into things or become clumsy?
Often
Sometimes
Never
30. Do you suffer from anxiety?
Often
Sometimes
Never
31. Would you consider yourself a perfectionist?
Often
Sometimes
Never
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