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