Dyslexia Screening Test

8/3/2019 Dyslexia Screening Test

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DYSLEXIA SCREENING FORM

General Information

1. Is there anything in your medical history that could explain your difficulties?

YES NO If so, what?

2. Did you always had academic difficulties? YES NO If so, what?

3. Did you have an eye examination?

YES NO If so, when.

4. Do you have any eyesight problems?

YES NO If so, please describe.

5. Did you have a hearing examination?

YES NO If so, when

6. Do you have any hearing problems?

YES NO If so, please describe. Last hearing examination?

General Indications of Dyslexia

1. Did someone in your family have reading, writing and/or speaking difficulties?

YES NO If so, what?

2. Do you have a central auditory processing problem?

YES NO If so, when.

3. Did you have tubes in your ears?

YES NO If so, please describe. Last hearing examination?

4. Do you have difficulty hearing what people say?


5. Did you have repeated ear infections?

YES NO If so, at what age.

6. Do you have an average or above average IQ but not doing do well academically oron tests/interviews?

YES NO

7. Are you forgetful?

YES NO

©2005 Canadian Dyslexia Centre (CDC) Inc.




8. Do you have difficulty concentrating?

YES NO

9. Do you have good days and bad days?

YES NO

10. Do you have poor articulation?

YES NO

11. Do you feel that “the other person’’ don’t get the big picture or just don’t get it?

YES NO

12. Do you have difficulty in “getting out” what you want to say?

YES NO

13. Are you “all over the place’’ when answering question?

YES NO14. Do you use mainly “simple” sentence structure?

YES NO

15. Do you use incorrect sentence structure?

YES NO

16. Do you feel that some persons ‘’go on and on’’ when speaking?

YES NO

17. Have some persons told you that ‘’’you go on and on’’ when speaking?

YES NO

18. Do you have at tendency to forget names of common objects and people?

YES NO

19. Do you have difficulty answering a question on a specific subject within a time limit?

YES NO

20. Do you often omit words when speaking?

YES NO

21. Do you often mispronounce words when speaking? YES NO

22. Do you often misuse words when speaking?

YES NO

23. Do you finish your sentences when speaking?

YES NO





24. Do you often confuse syllables in speech – amulinum, sghapetti?

YES NO

25. Do you often forget what you were going to say?

YES NO

26. Do you finish your sentences when speaking?

YES NO

27. Do you forget to proof read your examination paper?

YES NO

28. Do you take an inordinate time to write a term/essay paper?

YES NO

29. Do you lack of organisation in notes?

YES NO30. Do you often misread examination questions?

YES NO

31. Do you have difficulty understanding your own notes?

YES NO

32. Do you have difficulty sticking to the question?

YES NO

33. Do you suffer from extreme stress during examinations/interviews?

YES NO

34. Do you often feel that you can ‘’read someone’s mind’’?

YES NO

35. Do you find difficulty in telling left from right?

YES NO

36. Are you left-handed?

YES NO I DON’T KNOW

37. Which foot do you use to kick a ball?LEFT RIGHT EITHER

38. If you look though a tube, like a telescope, which eye do you use?

LEFT RIGHT





39. Do you hesitate before writing letters or numbers because you forget how to write

them?

YES NO

40. Do you find it difficult to say the months of the year forward? YES NO

41. Do you find it difficult to say the months of the year backward?

YES NO

42. Do you have difficulty following a sequence of verbal instructions?

YES NO

43. Are you known to be clumsy?

YES NO

44. Do you mix up dates and times and miss appointments?

YES NO

45. Do you have a poor sense of direction, do you get lost easily?

YES NO

46. Do you tend to get telephone numbers mixed up when you dial?

YES NO

47. Do you find it difficult to take messages on the telephone?

YES NO48. Did you or do you find it hard to learn your multiplication tables?

YES NO

49. Did you or do you have difficulty learning to tell time?

YES NO

50. Do you often mix up numbers like 67 and 76, or 234 and 423?

YES NO

51. Do you often make mistakes when writing checks/cheques?

YES NO

52. Did you change school often?

YES NO If yes, how many times?

53. Did you study hard at school, but had poor results on tests?

YES NO





54. Did you often miss school?

YES NO If yes, explain.

55. Do you remember being afraid to go to school?

YES NO If yes, please say in what grade and explain.

56. Did you receive remedial help at school?


57. Did you repeat any grade at school?


58. Where you in a special class at school?


59. Were you usually slow to finish your work in school?

YES NO60. Do you remember feeling frustrated at school?

YES NO

61. Do you perform better orally than in writing on tests?

YES NO

62. Which part of school work did you find hard?


63. What were your favourite subjects at school?


64. What were your worst subjects at school?


65. Do you enjoy sports?


66. Did you have many friends at school?

YES NO If no, please describe.

67. Do you read? YES NO

68. Do you change words when reading - lamp for light, kitchen for chicken?

YES NO

69. Do you guess at the words?

YES NO





70. Do you read by sounding out words?

YES NO

71. Do you read slowly?

YES NO

72. Is your reading choppy?

YES NO

73. Do you have difficulty reading aloud?

YES NO

74. Does it take you a long time to read a page in a book?

YES NO

75. Do you often reread sentences?

YES NO76. Do you often forget how to spell words?

YES NO

77. Do you see the ‘’word’’ written in your head?

YES NO

78. Do you usually spell a word by the way its sounds?

YES NO

79. Do you have difficulty planning and organizing essays?

YES NO

80. Do you have difficulty with punctuation?

YES NO

81. Do you have difficulty knowing when to start or finish a paragraph?

YES NO

82. Do you have difficulty with grammar and syntax?

YES NO

83. Is your handwriting slow and messy? YES NO

84. Do you have difficulty ‘’putting your thoughts down on paper’’?

YES NO

85. Do you often have headaches when reading?

YES NO






86. Do you sometimes see white lines, rivers or patterns in printed text?


87. Do you feel that the ‘’words move around’’ when you read?


88. Do you feel that the ‘’words get jumbled up’’ when you read?


89. Do you have difficulty reading small print?


90. Do you have difficulty reading on white paper?


91. Do you difficulties with multiple choice tests?

YES NO If so, please describe.92. Do you feel nauseated when looking at horizontal blinds/ lines in fabric?


93. Do you feel nauseated when riding in a car, escalator or elevator?

YES NO

94. Do you have difficulty copying from the board?

YES NO

95. Do you have difficulty taking notes at speed?

YES NO

96. Do you find it difficult and confusing to fill out forms?

YES NO

97. Do you dislike reading instructions?

YES NO

Dyslexia Screening Test

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