When you started school, did you have problems learning to read?:

Did you have difficulties learning to write?:

Were there difficulties learning to do joined-up writing?:

Did you have difficulty learning to tell the time from an analogue clock?:

Did you have problems learning to ride a bicycle?:

Did you/Do you suffer from travel sickness?:

In the first 8 years of your life did you have any illnesses involving high temperatures, convulsions or delirium? (Please give details):

In the first 8 years of your life did you continue to suffer from colds, chest infections or ear problems? (Please give details):

As a youngster when doing gymnastics did you have more difficulty learning to do forward rolls, handstands, balancing or jumping compared to your classmates?:

Did you suffer from regular and severe headaches around the age of puberty?:

How old were you when your problems started?:

What symptoms did/do you have?:

Is there any one time or place where your symptoms are at their worst (Please give details)?:

Can you go out alone?: Often Sometimes Never

Do you have feelings that at times you will fall over?: Often Sometimes Never

Do you see things moving which you know cannot move i.e. buildings etc?: Often Sometimes Never

Do you ever feel that your eyes will not work properly at times i.e. they do not focus, play tricks on you?: Often Sometimes Never

Do you suffer from feelings of nausea?: Often Sometimes Never

Do you have feelings of dizziness?: Often Sometimes Never

Do you have feelings of dizziness when lying in bed?: Often Sometimes Never

Do you suffer from migraine?: Often Sometimes Never

Do you feel that you have poor balance?: Often Sometimes Never

Do you feel you have poor coordination?: Often Sometimes Never

Are you very sensitive to bright lights?: Often Sometimes Never

Would you say you are more sensitive to sound than others?(Please give details):

Do you have problems in discriminating your lefts and rights?:

When you are writing, do you find that after a time you begin to make silly mistakes, such as putting letters and/or words in the wrong order, or your ability to spell even simple words becomes difficult? (Please give details):

When you are very tired do you find that you know what you want to say but the words come out jumbled up?:

When you are tired do you find that your coordination regresses and you bump into things or become clumsy? (Please give details):

Please use the space below to provide us with any more information that you feel may be of relevance: