Patient Questionnaire

1. Basic Information

1.1. Child’s surname, first name

1.2. Date of birth, age

1.3. Child’s gender
boy girl

1.4. Date of the session you will participate in:

1.5. Phone number:

1.6. Email address:

2. Pregnancy and Birth History

2.1. Which pregnancy and birth (number in order)?

2.2. Type of delivery (natural birth / cesarean section)

2.3. At which week of pregnancy did the birth occur?

2.4. Birth weight

2.5. Was labor induced (e.g., oxytocin)?

2.6. Were obstetric instruments used: vacuum extractor, forceps?

2.7. Was manual extraction of the fetus performed?

2.8. Fetal presentation (cephalic, breech, etc.)

2.9. Apgar score; if less than 10, specify the reason for reduction

2.10. Skin color after birth, did the child cry immediately?

2.11. Was the sucking reflex present at birth?

3. Medical History and Vaccinations

3.1. Has the child received vaccinations?

3.2. If vaccinations were discontinued — at what age and for what reason?

3.3. Was there a reaction to vaccination:
• DTP (pertussis–diphtheria–tetanus)
• MMR (measles–rubella–mumps)

4. Onset of Problems and Possible Causes

4.1. At what age were the first problems noticed?

4.2. What specific signs concerned you?

4.3. What do you associate or suspect as the cause of deterioration?

4.4. What could the child do 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 were performed (MRI, EEG, genetics, etc.)?
Results:

5.3. Is there an established diagnosis?nformation

5.4. What therapy or treatment improves the child’s condition? Are the improvements temporary or stable?age

6. Behavioral Features

6.1. Does the child have unusual or strange behavior? How does it manifest?

6.2. Does the child have eye contact? Constant or episodic?

6.3. Aggression, self-aggression, sudden mood swings, crying without reason

6.4. Does the child need strong touches or hugs? Does the child cling tightly?

6.5. Reaction to loud noises

6.6. Does the child prefer the position “head down” or hanging the head off the bed?

7. Sleep and Sleep Behavior

7.1. How does the child sleep?

7.2. Does the child wake between 1:00 and 3:00 a.m.?

7.3. Does the child scream in sleep? Any disorientation upon waking?

7.4. Does the child sweat during sleep (head, limbs)? Or, on the contrary, not at all?

7.5. Cold hands or feet at night?

7.6. Does the child uncover during sleep, throw off the blanket?

8. Neurological Signs

8.1. Does the child tilt the head backward during sleep?

8.2. Any strabismus, nystagmus?

8.3. Epilepsy, changes on EEG

8.4. Coordination problems (unstable gait, difficulty with bicycle)

8.5. Walking on tiptoes

8.6. Unable to jump in place

8.7. Can the child hold toys in both hands simultaneously?

9. Motor Development

9.1. Problems with fine motor skills (grasping, manipulating small objects)

9.2. Hypertonus of upper/lower limbs

9.3. Increased or decreased salivation

10. Sensitivity and Pain

10.1. Does the child have a high pain threshold?

10.2. Does the child cry when injured or only when comforted?

11. Teeth and ENT Conditions

11.1. Delayed tooth eruption

11.2. Frequent rhinitis or sinus infections

11.3. Aggression or displeasure during hair brushing

12. Gastrointestinal and General Condition

12.1. Intestinal problems (constipation, diarrhea)

12.2. Reaction to weather changes

12.3. Cold hands and feet during the day...

12.4. Poor or frequent absence of sweating

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Patient Questionnaire

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