1. Child over Aged 4

Please answer this section if your child is over aged 4

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

* 2. Please mark the skills your child was able to achieve from aged 4 or older.

  Yes Sometimes Initally Yes (but lost this skill) No Don't know
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 experienced after the age of 4 years?

  Yes - as per last year Yes - new this year Previously Yes - But not anymore Sometimes No Don't Know
Visual Problems
Prolonged Screaming Episodes
Temperature control problems
Scoliosis (spinal curve)
Hip Displacement
Dystonia / Dystonic spasms
Movement Disorder / Tremor
Recurrent Chest Infections / Pneumonias

* 4. Which of the following has your child had (or used) between their birth and today?
(please include previous positive responses to the same questions in Sections 4, 5, 6 and 7 and if new since the age of 4 please include details of the age your child had this in Q6)

  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
Jejunostomy or Duodenostomy
Central IV Line
Baclofen Pump (for Dystonic Spasms)
Other (please give details in Q6)

* 5. If your child has had a subsequent MRI scan between the ages of 3 and 4 and you were informed of any unusual features within this scan - please give details below. Particularly if there were any new features not noted on the previous MRI.
(If they have not had one during this time - please write n/a)

* 6. Further Information: