Brain Solutions
The Developmental Re-education Centre

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Questionnaires

If you are interested in attending one of our Initial Training Sessions, kindly completely the Questionnaire A and return it to us by e-mail or post. If we feel we can help you with your child, we will then tell you when the next Initial Training Session is, and we will confirm your appointment.

Please also send us a typical week's menu for your child.

We will endeavour to see your child in a country nearest to where you live.

If your child is attending a normal school but has only problems with reading, writing, behaviour or concentration, please complete Questionnaire B.


Download: Questionnaire A - Questionnaire B - Menu


Questionnaire A
Child's name
Date of birth
Parent's names
Address
Telephone
Fax
E-mail
Cause of injury or  medical diagnosis (if know)

Please describe what your child is capable of doing in each of the following areas, with the age or date if possible.

Vision

(e.g. First smile, recognition of familiar objects, interest in pictures, recognition of words, ability to read)

Hearing and Understanding

(e.g. Reaction to sudden loud sounds, hypersensitivity to environmental sounds, understanding commands, understanding of colours and space and time concepts, listening to undirected conversations)

Tactile Ability

(e.g. appropriate reaction to pain and light touch, awareness and identification of objects placed in his/her hands)

Mobility

(e.g. Crawling on his/her tummy and on hands and knees, walking, running, hopping, climbing, riding a tricycle or a bicycle)

Language

(e.g. Crying, range of babbling sounds, words, phrases, sentences, articulation of words)

Manual Ability

(e.g. palmar grasp, pincer grip, dressing including fasteners, screwing, pouring, writing)

Has your child ever had convulsions ?

YES
NO
If so, how often, what type of convulsion and how long do they last ?

Please note the name and dose of any anticonvulsant medication

   


Questionnaire B
Child's name
Date of birth
Parents' name
Address
Telephone
Fax
E-mail

Is there any history of learning difficulties in your immediate family ?

YES
NO

Were there any medical problems during the pregnancy ?

YES
NO

Was the birth process unusual or prolonged in any way ?

YES
NO

Was your child born early or late for term (more than 2 weeks early or more than 10 days late) ?

YES
NO

Was your child's birth weight below 5 lbs (pounds) ?

YES
NO

Did your child have any difficulty feeding in the first weeks of life, or in keeping food down ?

YES
NO

Was your child extremely demanding in the first 6 months of life ?

YES
NO

Did your child miss out the 'motor stage' of crawling on his or her tummy and creeping on hands and knees ?

YES
NO

Was your child late at learning to walk (16 months or later would be considered late) ?

YES
NO
Was your child late at learning to talk (2-3 word phrases at 18 months or later would be considered late) ?
YES
NO
Did your child have difficulty in, for example, learning to dress himself or herself, do up buttons or tie shoelaces beyond the age of 6-7 years ?
YES
NO

Does your child suffer from allergies ?

YES
NO

Did your child have an adverse reaction to any of his or her vaccinations ?

YES
NO

Did your child suck his or her thumb beyond the age of 5 years ?

YES
NO

Did your child continue to wet the bed, albeit occasionally, above the age of 5 years ?

YES
NO
Does your child suffer from travel sickness  ?
YES
NO
Did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock ?  
YES
NO

Did your child have an unusual degree of difficulty learning to ride a bicycle ?

YES
NO

Did your child suffer from frequent ear, nose, throat or chest infections ?

YES
NO
In the first 3 years of life, did your child suffer from any illnesses involving extremely high temperature, delirium or convulsion ?
YES
NO
Does your child have difficulty catching a ball, and stand out as 'awkward' in PE classes ?
YES
NO

Does your child have difficulty sitting still for even a short period of time ?

YES
NO

If there is a sudden unexpected noise, does your child over-react ?

YES
NO

Does your child have reading difficulties ?

YES
NO

Does your child have writing difficulties ?

YES
NO

Does your child have copying difficulties ?

YES
NO

With Acknowledgements to The Institute of Neuro-Physiological Psychology, Chester

   

Typical week's menu
Child's name
Date of birth
Parents' name
Address
Telephone
Fax
E-mail
 
Monday Breakfast
Snack
Lunch
Snack
Evening meal
Tuesday Breakfast
Snack
Lunch
Snack
Evening meal
Wednesday Breakfast
Snack
Lunch
Snack
Evening meal
Thusday Breakfast
Snack
Lunch
Snack
Evening meal
Friday Breakfast
Snack
Lunch
Snack
Evening meal
Saturday Breakfast
Snack
Lunch
Snack
Evening meal
Sunday Breakfast
Snack
Lunch
Snack
Evening meal
   

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