Brain Balance Left Brain Delay Questionnaire: Please answer 'Yes' if you or your child shows parts or all of the characteristic, or 'No' if it does not apply. Please complete 100 questions for accurate results. Thank you!

Welcome to the Brain Balance Questionnaire

Thank you for answering this questionnaire about your child's brain function.

Question Title

1. Your information (Required.)

Name

Email Address

This questionnaire is a master checklist of characteristics of a child with possible brain imbalance. There are 100 statements for the left side of the brain, and 100 questions for the right side of the brain (this questionnaire is for the Left Brain Delay). Your child will show a certain number of characteristics. There will always be a 'normal' amount of characteristics your child shows, either regularly, or randomly. The significance is to find the scale at which there might be a delay in either the right side, left side, or both sides of the brain. The purpose of finding this specific information is to design and create a proper program to train and strengthen the brain to function and develop normally and optimally. Please answer Yes or No for each question. When you are finished with this questionnaire, please go on to complete the Right-Brain Delay Questionnaire. Thank you!

Question Title

2. Is this for you or your child?

My child

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3. How old is your child?

0-3

3-6

6-9

9-12

12+

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4. Female or Male?

Female

Male

Question Title

* 1. Your information (Required.)

Question Title

* 2. Is this for you or your child?

Question Title

* 3. How old is your child?

Question Title

* 4. Female or Male?

1. Your information (Required.)

2. Is this for you or your child?

3. How old is your child?

4. Female or Male?