Questionnaire 1. Basic Information 1.1. Child’s surname and first name 1.2. Date of birth Age 1.3. Child’s sex boygirl 1.4. Date of the session/camp you will attend 1.5. Telephone number 1.6. E-mail address 2. Pregnancy and Birth History 2.1. Which pregnancy and delivery number was this? 2.2. Type of delivery natural birthcesarean section 2.3. In which week of pregnancy did the birth occur? 2.4. Birth weight 2.5. Was labor induced, e.g., oxytocin? yesnoI don’t know 2.6. Were obstetric instruments used: vacuum extractor, forceps? yesnoI don’t know 2.7. Was manual extraction/expulsion of the fetus performed? yesnoI don’t know 2.8. Fetal position, e.g., head first, breech 2.9. Apgar score; if not 10 points, state the reason for the lower score 2.10. Skin color after birth; did the child cry immediately? 2.11. Was the sucking reflex present at birth? yesnoI don’t know 3. Medical History and Vaccinations 3.1. Has the child received vaccinations? yesnopartially 3.2. If vaccinations were discontinued, from what age and for what reason? 3.3. Was there a reaction to the DTP vaccine? yesnoI don’t know Description of the reaction to DTP Was there a reaction to the MMR vaccine? yesnoI don’t know Description of the reaction to MMR 4. Onset of Problems and Possible Causes 4.1. At what age did you first notice problems? 4.2. What signs worried you? 4.3. What do you associate with or suspect caused the worsening of the condition? 4.4. What skills did the child have before the condition worsened? 5. Current Developmental Status 5.1. What skills does the child currently have: walking, standing, speech, self-care? 5.2. What examinations have been performed, e.g., MRI, EEG, genetics? Results 5.3. Has a diagnosis been established? 5.4. What therapy or treatment improves the child’s condition? Are improvements temporary or permanent? 6. Behavior 6.1. Does the child have unusual or peculiar behavior? How does it manifest? 6.2. Is there eye contact? Constant or occasional? 6.3. Aggression, self-aggression, sudden mood changes, crying without reason 6.4. Does the child need strong touch or hugs? Do they press tightly against others? 6.5. Reaction to sudden sounds 6.6. Does the child prefer a “head-down” position or hanging their head off the bed? 7. Sleep and Sleep Behavior 7.1. How does the child sleep? 7.2. Does the child wake up between 1:00–3:00 a.m.? yesnosometimes 7.3. Does the child scream during sleep? Are they disoriented upon waking? 7.4. Does the child sweat during sleep, e.g., head, limbs? Or not sweat at all? 7.5. Does the child have cold hands or feet at night? yesnosometimes 7.6. Does the child uncover themselves or kick off the blanket during sleep? yesnosometimes 8. Neurological Symptoms 8.1. Does the child tilt their head backward during sleep? yesnosometimes 8.2. Is there strabismus or nystagmus? 8.3. Epilepsy, EEG abnormalities 8.4. Coordination problems, e.g., unsteady gait, difficulty riding a bicycle 8.5. Walking on tiptoes yesnosometimes 8.6. Unable to jump in place yesnonot applicable 8.7. Can the child hold toys in both hands at the same time? yesnosometimes 9. Motor Development 9.1. Problems with fine motor skills, e.g., grip, handling small objects 9.2. Hypertonia of the upper/lower limbs 9.3. Increased or decreased drooling 10. Sensitivity and Pain 10.1. Does the child have an increased pain threshold? yesnoI don’t know 10.2. Does the child cry immediately after injury, or only when comforted? 11. Teeth and ENT Problems 11.1. Delayed tooth eruption yesnoI don’t know 11.2. Frequent colds or sinus infections yesnosometimes 11.3. Aggression or dissatisfaction when hair is brushed yesnosometimes 12. Gastrointestinal Tract and General Condition 12.1. Bowel problems, e.g., constipation, diarrhea 12.2. Reaction to weather changes 12.3. Cold hands and feet during the day yesnosometimes 12.4. Reduced sweating or frequent absence of sweating I give my explicit consent for NEUROSPECTRUM sp. z o.o. to process my child’s personal data, including data concerning health, development, diagnoses, examinations and therapies, for the purpose of analyzing the questionnaire, making contact, and preparing or providing services. I know that I may withdraw my consent at any time. I declare that I am the child’s parent or legal guardian, or a person authorized to provide the child’s data.
