Adult Screening Questionnaire

The adult screening questionnaire consists of 6 parts as follows:

• General Information
• Neurology
• Schooling
• Adult Life and Work
• Nutrition
• Madaule Auditory Screening

Please complete the questionnaire and submit it for evaluation; alternatively print the questionnaire and mail it to the following address:

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.

When submitted the questionnaire is transmitted in a non-readable form to protect your privacy and is treated confidentially once received.

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:

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.