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Adult Screening Questionnaire
The Insititure for Neuro-Physiological Psychology
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Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
Telephone
Your answer
Email Adress
Your answer
Has a diagnosis been given at any time i.e. Dyslexia, Dyspraxia, ADHD? If so, please state:
Your answer
Are you currently taking any prescribed medication? Please specify:
Your answer
What investigations/interventions have you received in the past?
Your answer
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