Adult Neuro Developmental Therapy Questionnaire

Prior to our initial consultation you will be asked to complete a detailed questionnaire which will allow us to gain a better understanding of your requirements.

Prior to our initial consultation you will be asked to complete a detailed questionnaire which will allow us to gain a better understanding of your requirements.

SECTION 1 – PREGNANCY, BIRTH AND INFANCY

  • When your mother was pregnant with you did she have any medical problems?
  • Were you artificially induced?
  • Were you born either 14 days early or late?
  • Was the birth unusual or difficult in any way?
  • Was there anything unusual about the way you looked at birth (jaundice, blue baby, etc.)?
  • Did you weigh less than 5lbs. at birth?
  • In the first three months of life were you the sort of child that had projectile vomiting, accompanied by screaming sessions?
  • During the first three months of life were you the “good baby”, hardly moving, very quiet – to the point that your parents had to check to see if you were still breathing?
  • Between six and tweleve months of age did you become a very demanding child, needing little sleep and a lot of stimulation and attention?
  • When old enough to sit up by yourself in the cot or pram, did you start to rock backwards and forwards, sometimes violently enough to move the cot across the floor, or pram against the brake?

SECTION 2 – Schooling

Did you have difficulty learning how to:

  • Dress yourself – do up your buttons, laces, tie correctly?
  • Read. Was reading more difficult for you to master than the majority of the other members in your class?
  • Write. Was it harder for you to learn how to write than for the others in your class.
  • Tell the time. Did you find it hard to learn how to read a clock?
  • Catch. Were you a butterfingers, always dropping the ball or avoiding games like cricket or rounders?
  • Co-ordinate. Did you find it hard to do such exercises as cartwheels?
  • Sit quietly. Were you the classroom fidget or chatterbox?
  • Up to puberty did you start to suffer with regular travel sickness?
  • Do you still tend to print rather than use longhand?
  • After puberty did you start to suffer with regular headaches or migraines?
  • Did you regularly feel dizzy or faint whilst standing in assembly?
  • If the teacher asked you a question in front of the class to which you knew the answer, would you go over it in your mind, to be sure, instead of coming straight out with it?

SECTION 3 – Current Functioning

  • If a passenger in a car or coach, do you find it difficult to read a book whilst travelling?
  • Do you now suffer with regular headaches which are made worse by physical tension or stress?
  • Do you find bright light disturbing?
  • Do you find that your tolerance to noise is lower than other members of your family or friends?
  • Whilst amongst a group of people, do you find that if several are talking at the same time you become confused, with rising levels of anxiety or stress?
  • Do you tend to rock during periods of tension or anxiety?
  • If you have to stand in a busy crowded place, do you start to feel rising levels of tension or anxiety and feel light-headed, dizzy or faint?
  • If you walk out over the sea on a pier, does the movement of the sea as seen through the gaps in the boards make you feel uneasy?
  • Do you have trouble with “lefts” and “rights” when giving or receiving directions?
  • Whilst writing is there a tendency for your spelling to get worse?
  • Do you tend to over-react to sudden loud noises?

FINAL QUESTIONS

KEY: 0 = NEVER, 1 = A LITTLE, 2 = FROM TIME TO TIME,  3 = QUITE A LOT, 4 = FREQUENTLY

  • I get headaches.
  • I have feelings of nervousness.
  • I get words or thoughts that I cannot put out of my mind.
  • I get feelings of dizziness or light-headedness.
  • I have a loss of sexual interest.
  • I have feelings of antagonism towards others.
  • I feel that my thoughts are being controlled.
  • I feel that others are to blame for most of my problems.
  • I find it hard to remember things.
  • I worry about being untidy, or careless.
  • I get easily upset or irritated.
  • I get a pain in the chest.
  • I don’t like open places, or going out into the street.
    I lack energy, or feel sluggish.
  • I have thoughts of killing myself.
  • I hear voices that others do not hear.
  • I feel unsteady, or get trembling feelings.
  • I feel that most people are unreliable.
  • I have a poor appetite.
  • I find it easy to cry.
  • I feel uneasy with the opposite sex.
  • I feel trapped.
  • I get sudden fears without reason.
  • I get uncontrollable outbursts of anger.
  • I’m afraid to go out alone.
  • I blame myself for everything.
  • I get low back pains.
  • I find it difficult to get things done.
  • I feel low.
  • I worry too much about things.
  • I have no interest in anything.
  • I get feelings of fear and anxiety.
  • I get easily hurt.
  • I feel that others can read my mind.
  • I feel that others don’t care about me, or understand me.
  • I feel that others are unfriendly, or disapprove of me.
  • I have to do things carefully to ensure that they are done correctly.
  • I get a racing, pounding, heart feeling.
  • I get feelings of nausea or upset stomach.
  • I feel that I am inferior.
  • I get pains or tenderness in the muscles.
  • I feel that others are watching or talking about me.
  • I find it hard to go to sleep.
  • I have to go back over things to ensure that they have been done correctly.
  • I find it hard to make decisions.
  • I am frightened to use public transport.
  • I find it difficult to breathe.
  • I get hot and cold flushes running through my body.
  • I avoid certain places because they make me feel uneasy.
  • I feel that my mind has gone blank.
  • I get feelings of numbness, or pins and needles, in parts of my body.
  • I feel a lump in my throat.
  • I have feelings of hopelessness about the future.
  • I find it hard to concentrate.
  • I have feelings of weakness in parts of my body.
  • I feel tense or over-excited.
  • I get feelings of heaviness in my arms or legs.
  • I have thoughts about death, and what it’s like to die.
  • I feel that I am over-eating.
  • I feel uneasy when people look at me, or talk about me.
  • I wake early in the morning and cannot get back to sleep.
  • I have rituals to help me through the day.
  • I have worried or disturbed sleep.
  • I have impulses to break or smash things.
  • I have thoughts or ideas that others do not have.
    I am preoccupied with myself, even in the company of others.
    I feel uneasy in crowded places.
  • Everything is tiring.
  • I get sudden attacks of panic, or anxiety.
  • I do not like going out socially.
  • I often find myself in heated discussions or arguments.
  • I feel nervous when left on my own.
  • Others do not appreciate enough the things that I do.
  • I feel alone even in the company of others.
  • I feel restless and unable to sit still.
  • I feel worthless.
  • Familiar things seem strange and unreal.
  • I scream and throw things.
  • I feel like running away.
  • I’m afraid that I might faint when out with other people.
  • I think that others would use me if they had the chance.
  • I have disturbing sexual thoughts.
  • I think that I should be punished for my sins.
  • I have a compulsive need to get things done.
  • I think that I have something wrong physically.
  • I never feel close to anyone.
  • I feel guilty.
  • I think that there is something wrong with my mind.