MPEI Questionnaire - Page 4 of 9 - Up to Age 1 (or Older) Survey

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

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

Please can you provide your child's details below: Name
Date of Birth

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	*Please mark the developmental milestones your child reached in their FIRST year of life Smiling Yes	Smiling Sometimes	Smiling Initally Yes (but lost this skill)	Smiling No	Smiling Don't know
Vocalizing	Vocalizing Yes	Vocalizing Sometimes	Vocalizing Initally Yes (but lost this skill)	Vocalizing No	Vocalizing Don't know
Fixing and following	Fixing and following Yes	Fixing and following Sometimes	Fixing and following Initally Yes (but lost this skill)	Fixing and following No	Fixing and following Don't know
Gripping an object	Gripping an object Yes	Gripping an object Sometimes	Gripping an object Initally Yes (but lost this skill)	Gripping an object No	Gripping an object Don't know
Holding head up	Holding head up Yes	Holding head up Sometimes	Holding head up Initally Yes (but lost this skill)	Holding head up No	Holding head up Don't know
Eating solid foods	Eating solid foods Yes	Eating solid foods Sometimes	Eating solid foods Initally Yes (but lost this skill)	Eating solid foods No	Eating solid foods Don't know
Sitting unassisted	Sitting unassisted Yes	Sitting unassisted Sometimes	Sitting unassisted Initally Yes (but lost this skill)	Sitting unassisted No	Sitting unassisted Don't know
Pulling up to standing	Pulling up to standing Yes	Pulling up to standing Sometimes	Pulling up to standing Initally Yes (but lost this skill)	Pulling up to standing No	Pulling up to standing Don't know

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

	Yes	Sometimes	No	Don't Know
Reflux/Vomiting	*Which of the following problems has your child encountered in their FIRST year of life? Reflux/Vomiting Yes	Reflux/Vomiting Sometimes	Reflux/Vomiting No	Reflux/Vomiting Don't Know
Constipation	Constipation Yes	Constipation Sometimes	Constipation No	Constipation Don't Know
Visual Problems	Visual Problems Yes	Visual Problems Sometimes	Visual Problems No	Visual Problems Don't Know
Prolonged Screaming Episodes	Prolonged Screaming Episodes Yes	Prolonged Screaming Episodes Sometimes	Prolonged Screaming Episodes No	Prolonged Screaming Episodes Don't Know
Temperature control problems	Temperature control problems Yes	Temperature control problems Sometimes	Temperature control problems No	Temperature control problems Don't Know
Scoliosis (spinal curve)	Scoliosis (spinal curve) Yes	Scoliosis (spinal curve) Sometimes	Scoliosis (spinal curve) No	Scoliosis (spinal curve) Don't Know
Hip Displacement	Hip Displacement Yes	Hip Displacement Sometimes	Hip Displacement No	Hip Displacement Don't Know
Dystonia / Dystonic spasms	Dystonia / Dystonic spasms Yes	Dystonia / Dystonic spasms Sometimes	Dystonia / Dystonic spasms No	Dystonia / Dystonic spasms Don't Know
Movement Disorder / Tremor	Movement Disorder / Tremor Yes	Movement Disorder / Tremor Sometimes	Movement Disorder / Tremor No	Movement Disorder / Tremor Don't Know
Recurrent Chest Infections / Pneumonias	Recurrent Chest Infections / Pneumonias Yes	Recurrent Chest Infections / Pneumonias Sometimes	Recurrent Chest Infections / Pneumonias No	Recurrent Chest Infections / Pneumonias Don't Know
Asthma	Asthma Yes	Asthma Sometimes	Asthma No	Asthma Don't Know

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)	*Which of the following treatments has your child had (or used) in their FIRST year of life? Fundoplication (tightening of gullet to reduce sickness) Yes	Fundoplication (tightening of gullet to reduce sickness) No	Fundoplication (tightening of gullet to reduce sickness) Don't Know
Pyloroplasty (loosening the stomach exit to aid emptying)	Pyloroplasty (loosening the stomach exit to aid emptying) Yes	Pyloroplasty (loosening the stomach exit to aid emptying) No	Pyloroplasty (loosening the stomach exit to aid emptying) Don't Know
Spinal Brace	Spinal Brace Yes	Spinal Brace No	Spinal Brace Don't Know
Spinal Surgery	Spinal Surgery Yes	Spinal Surgery No	Spinal Surgery Don't Know
Hip Surgery	Hip Surgery Yes	Hip Surgery No	Hip Surgery Don't Know
Continual Oxygen Therapy	Continual Oxygen Therapy Yes	Continual Oxygen Therapy No	Continual Oxygen Therapy Don't Know
Ketogenic Diet	Ketogenic Diet Yes	Ketogenic Diet No	Ketogenic Diet Don't Know
NG Feeding Tubes	NG Feeding Tubes Yes	NG Feeding Tubes No	NG Feeding Tubes Don't Know
Gastrostomy	Gastrostomy Yes	Gastrostomy No	Gastrostomy Don't Know
Jejunostomy or Duodenostomy	Jejunostomy or Duodenostomy Yes	Jejunostomy or Duodenostomy No	Jejunostomy or Duodenostomy Don't Know
Central IV Line	Central IV Line Yes	Central IV Line No	Central IV Line Don't Know
Baclofen Pump (for Dystonic Spasms)	Baclofen Pump (for Dystonic Spasms) Yes	Baclofen Pump (for Dystonic Spasms) No	Baclofen Pump (for Dystonic Spasms) Don't Know
Other (please give details in Q6)	Other (please give details in Q6) Yes	Other (please give details in Q6) No	Other (please give details in Q6) Don't Know

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)

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:

Further Information:

MPEI Questionnaire - Page 4 of 9 - Up to Age 1 (or Older)
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1. First Year of Life

MPEI Questionnaire - Page 4 of 9 - Up to Age 1 (or Older)Exit this survey

1. First Year of Life

MPEI Questionnaire - Page 4 of 9 - Up to Age 1 (or Older)
Exit this survey