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Perinatal Insults and Functional/Academic Activities Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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1

What is the primary perinatal insult observed in the child?

Please select the primary perinatal insult from the following options.
2

Rate the level of difficulty in functional/academic activities of the child

Please rate the level of difficulty in functional/academic activities on a scale from 1 to 10.
3

Describe any specific functional or academic activity where the child faces challenges

Please provide a description of a specific functional/academic activity where the child faces challenges.
4

Has the child undergone any therapy or intervention for these difficulties?

Please select an option regarding therapy or intervention for the child's difficulties.
5

How often does the child engage in extracurricular activities?

Please select the frequency of the child's engagement in extracurricular activities.
6

Rate the child's overall happiness and well-being

Please rate the child's overall happiness and well-being on a scale from 1 to 10.
7

Are there any specific challenges faced by the child at school?

Please select any specific challenges faced by the child at school.
8

Does the child express any emotional concerns related to their difficulties?

Please select an option regarding the child's expression of emotional concerns.
9

Rate the level of support provided by the family for the child

Please rate the level of support provided by the family for the child on a scale from 1 to 10.
10

Are there any specific recommendations or suggestions from the caregivers for improvement?

Please provide any specific recommendations or suggestions for improvement from the caregivers.
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