The adult screening questionnaire consists of 6 parts as follows:
- General Information
- Adult Life and Work
- Madaule Auditory Screening
Please complete the questionnaire and submit it for evaluation; alternatively print the questionnaire and mail it to the following address:
110 West Town Lane
Bristol BS4 5DT
I charge £50.00 for the evaluation of the questionnaire which can be payed into my PayPal account. Should you continue with further treatment this £50.00 is set against further fees.
I appreciate that for many the early parts of this form may be difficulty to complete, include as much as you can but do not guess. You may also feel that many of the questions are intrusive. Please answer as honestly as you can; the purpose is not to make value judgements about your family, or your life style, but to help in the appraisal as to the type and extent of your difficulties.
The Questionnaire is in PDF format. You will need Adobe Reader to view and print this. If you do not have a copy of Adobe Reader you can down load one from:
Note: You will need to save the down loaded PDF form onto your computer before opening it in Adobe Reader. I cannot guarantee that all the facilities will work if you complete the form in a browser as many do not fully support PDF functionality.
Please note that part of the screening questionnaire was externally validated for INPP. A score of 7 or more on specific questions (asterisked) confirms a 98% probability of retention of Primitive Reflexes. Retention of Primitive Reflexes being the primary cause of neuro-developmental delay.