Parental Questionnaire That My Mother Did In Regards To My Neurodivergence

 Parental Questionnaire


This is a parental questionnaire that my mom answered so I can give to Dr. Levinson and Veteran Affairs Neurologists.

I got it from the book, Understanding Developmental Dyspraxia by Madeleine Portwood. I copied the questions in my book and had my mom answer them and then had her sign it to give to the Dr. Levinson and the Veteran Affairs neurologists.


Background Information

Is there any family incidence of learning disability, Dyslexia, Dyspraxia, autistic spectrum disorder, ADHD or diagnosed conditions?   My paternal uncle w/ Dyslexia, My brother w/ speech problems and hyperactivity, my niece diagnosed ADHD, Raymond's father had speech/auditory processing problems 

Is there any family incidence of allergy, eg. food intolerance, eczema or asthma?  my niece, my paternal aunt, my cousin, and I have asthma 

Is there a family history of epilepsy or diabetes? My paternal aunt, my great aunt, and I have Diabetes

Is there a family incidence of depression or psychiatric illness?  my father had depression and alcoholism, my brother had depression, and I had depression and anxiety 


Personal Details

Can you remember whether you had any illness during your pregnancy?  measles 

How did you your weight progress? went way up 


 When did you have your scan and was it repeated later during pregnancy?

 Were there any concerns? no

Was there anything unusual about the last trimester (6-9 months) no 

Did you a maintain a good diet? yes 

Did you smoke during pregnancy? no 

Did you take any medication? no

Any drugs taken? no

Were there any complications, eg. eclamsia? no 


Birth Details 

Stage Birth was delivered - 2 1/2 weeks early

Was delivery induced - yes

any indication of fetal distress before birth - no 

how long was the labor - 23 hours

 any concerns immediately after birth - no 


Developmental Profile

Child Presentation

Levels of activity (hyper,hypo) - hypo

feeding (was weight gain appropriate, any evidence of lactose intolerance) yes- weight gain appropriate, no evidence of lactose intolerance 

sleeping (settled quickly or very irritable) - settled quickly

 was he/she a demanding child? no 


Motor skills 

sitting independently - 4 months

crawling - 4 months

walking independently - 13 months


Social skills

finger feeding - 6 months

 coordinating a knife and fork - 4 years

 toilet trained - 3 1/2 years


Language 

made initial sounds (m,m-da,da) - 5 to 6 months

able to say 20+ distinguishable words - 5 years 

used 3+ words to construct simple phrases - 5 years

Were there any other difficulties during the first 12 months? severe ear infection at 3 months old 


Later Development 

hearing checked on - 4 yrs old

vision checked on - 4 yrs old

 Describe child's fine motor skills - poor 

Describe child's gross motor skills - poor 

Have there been any problems with health, eg. eczema, asthma? problems with whole milk and put on lowfat milk at 6 months.

At what age and which immunizations have been given?

Has the child had any additional assessment? (pediatrician, speech therapist, physio/occupatonal therapist, optometrist, psychologist) pediatrician, speech therapist, physio/occupational therapist, psychologist 


Do you have any additional information?

 Nuns in Grace Day preschool noticed problems with Raymond's speech. He was seen by a psychologist at Grace Day preschool, and he ruled out psychological problems. He recommended Raymond to go to Alta Regional Center for speech and hearing. Counselor at Sutter Diagnostic Center said that Raymond had a form of Dyslexia that involved his turning stuff around when he heard it,and so that affected his speech. He was trained to hear things differently. He had intensive speech therapy and motor skills therapy during 3 yrs of special education. He had problems with distinguishing left from right. He started off as a regular student in kindergarten. He was returned to mainstream education class in 3rd grade after 3 yrs of special education. There were no concerns about attention.


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