<Alive Health Center - Child Screening Questionaire
Marc DeMeester, D.C.
14828 W 6th Ave
Golden, CO 80401
303-601-3820

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Child Screening Questionnaire

The Child Screening Questionnaire is a neurological functional assessment designed to help assess the possibility of what we call a "Mechanoreceptive Brainstem Dysafferentation". Any one of the questions by themselves is not significant in assessing a problem but only in combination of multiple of the following circumstances or problems.
Is there any history of learning difficulties in your immediate family?
Were there any medical problems during the pregnancy?
Was the birth process unusual or prolonged in any way? E.g. CS, Forceps, etc.
Was your childs birth weight below 5lbs (pounds)?
Was your child born early or late for term (more than 2 weeks early or more than 10 days late)?
Did your child have any difficulty feeding in the first weeks of life?
Does your child have any digestive problems or disorders?
Was your child ever involved in a car accident or fallen on their head with no immediate signs of injury?
Was your child extremely needy in the first 6 months of life?
Did your child miss out on the motor stage of crawling on his or her tummy and creeping on hands and knees?
Did your child lack warm emotional expressions by the age of 6 months?
Was there any loss of speech or babbling or social skills at any age?
Was your child late at learning to walk (16 months or later would be considered late)?
Did your child have difficulty in learning to dress himself or herself beyond the age of 6-7 years?
Does your child suffer from allergies?
Does your child suffer from allergies?
Did your child have an adverse reaction to any of his or her vaccinations?
Did your child suck his or her thumb beyond the age of 5 years?
Did your child continue to wet the bed above the age of 5 years?
Does your child suffer from travel sickness?
Did your child find it very difficult to learn to tell the time from a traditional clock?
Did your child suffer from frequent ear, nose, throat or chest infections at any time in development?
In the first 3 years of life, did your child suffer from any illnesses involving extremely high temperatures, delirium or convulsion?
Does your child have difficulty catching a ball, doing forward rolls/somersaults and stand out as awkward in PE classes?
Does your child have difficulty sitting still for even a short period of time?
Does your child startle easily, or over-react with unexpected noises?
Please enter any additional information that you think may be relevant regarding the possible diagnosis of your child, including any previous diagnosis info:
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