Before your assessment

Screening questionnaire

This questionnaire gathers background history used alongside your INPP® assessment. It covers early development, nutrition-related symptoms and listening/auditory patterns. It takes most families 15–20 minutes.

Completing for a child Completing for an adult

Some questions below relate to early childhood and developmental history that you may not remember or know for certain — that's completely fine. Choose “I do not know” or leave a question blank wherever that applies; just complete what you can.

This form saves your answers in your own browser only, as you go — nothing is sent anywhere or stored on our servers. At the end, a summary is generated on-screen for you to copy, print, or read out during your call.

Details

Child & family details

Name of child

Date of birth

Address

Parent / Guardian

Tel no

Mobile no

Has a diagnosis been given at any time?

Is your child currently taking any prescribed medication? Please specify:

What investigations/interventions has your child received in the past?

What are the presenting symptoms?

Part 1 — Neurological

Historical & infancy

Part 2 — Nutritional

Screening questionnaire (Sheil)

Has your child suffered from any of the following at regular intervals? Please tick as appropriate.

Part 3 — Auditory (Madaule)

Developmental history & listening

Finally

How did you hear of INPP®?

Date questionnaire completed

Please add any additional information relevant to your child’s presenting problems

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Submitted

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The INPP Screening Questionnaire — devised by Blythe and McGlown © 1979, 1998, amended Goddard Blythe 2006. Nutritional section after Sheil. Auditory section after Madaule. For use within Helping Hand / INPP® UK assessments only.