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1. First Year of Life

Please answer this section if your child is nearly one or older

1. Please can you provide your child's details below:

2. Please mark the developmental milestones your child reached in their FIRST year of life

  Yes Sometimes Initally Yes (but lost this skill) No Don't know
Smiling
Vocalizing
Fixing and following
Gripping an object
Holding head up
Eating solid foods
Sitting unassisted
Pulling up to standing

3. Which of the following problems has your child encountered in their FIRST year of life?

  Yes Sometimes No Don't Know
Reflux/Vomiting
Constipation
Visual Problems
Prolonged Screaming Episodes
Temperature control problems
Scoliosis (spinal curve)
Hip Displacement
Dystonia / Dystonic spasms
Movement Disorder / Tremor
Recurrent Chest Infections / Pneumonias
Asthma

4. Which of the following treatments has your child had (or used) in their FIRST year of life?

  Yes No Don't Know
Fundoplication (tightening of gullet to reduce sickness)
Pyloroplasty (loosening the stomach exit to aid emptying)
Spinal Brace
Spinal Surgery
Hip Surgery
Continual Oxygen Therapy
Ketogenic Diet
NG Feeding Tubes
Gastrostomy
Jejunostomy or Duodenostomy
Central IV Line
Baclofen Pump (for Dystonic Spasms)
Other (please give details in Q6)

5. If your child has had an MRI scan in the FIRST year of their life and you were informed of any unusual features within this scan - please give details below:
(If they have not had one- please write n/a)

6. Further Information:

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