Adult Assessment Questionnaire

    If you find this form difficult the centre will help you. Please complete this form as fully as you can and return it to the Centre. It will help us to help you. The answers are entirely CONFIDENTIAL to Centre Staff and other Professionals directly concerned with you.

    First Name

    Surname Name

    Date of Birth

    Title MrMrsMissMsOther

    Your Address

    Postcode

    Home Telephone

    Work Telephone

    Mobile Telephone


    Family Background

    Have any family members had problems with any of the following?
    SpeakingReadingWritingSpellingMaths
    Which Relatives?

    What languages are spoken at home?

    Did your speech and language develop well? YesNo

    Did you receive Speech Therapy? YesNo
    If yes, please give details:

    Have you suffered any accidents? Any hospitalization? YesNo
    If yes, please give details:

    Medical History: Please give information regarding any illnesses or conditions that the assessor should be made aware of.

    Do you suffer from any of the following?
    Eczema YesNo
    Hay fever YesNo
    Migraine YesNo
    Epilepsy YesNo
    Light sensitivity YesNo
    Rheumatoid Arthritis YesNo
    Allergy YesNo
    Asthma YesNo
    Colour blindness YesNo
    If yes, please give details:

    Is your eyesight normal? YesNo

    Is your hearing normal? YesNo

    Suffered ear infections? YesNo

    Had grommets inserted in your ears? YesNo

    Had tonsils/adenoids removed? YesNo

    Do you have special interests/hobbies? YesNo
    If yes, please give details:

    Do you have any particular dislikes? YesNo
    If yes, please give details:



    Educational History

    Past Schools/Colleges Attended (Name of School) with Dates. One school per line and indicate in bracket if it Private School or State School

    Were there reasons for changing school other than age? YesNo
    If Yes, please give details:

    Have you had extra tuition or therapy? YesNo
    With whom?
    How often?
    When

    Have you been assessed by an educational psychologist? YesNo
    With whom?
    How often?
    When

    Do you have a copy of previous report(s)? YesNo
    If Yes, please give details:

    Have you been to a special School? YesNo
    If Yes, please give details:

    Have you received extra time in examinations? YesNo
    If Yes, please give details

    Have you ever had a Statement of Special Educational Needs? YesNo
    If Yes, please give details

    Were your difficulties ever recognised in school? YesNo
    If Yes, please give details

    Have you passed exams? YesNo
    Please give details (ie ”O” Levels, GCSE, “A” levels. RSA, City & Guides etc)

    Have you failed exams? YesNo
    If Yes, please give details:



    The Current Situation

    What is your present job?

    If you are still in full-time education, what are you hoping to do when you leave?

    Please list the jobs you have had

    If you are not in work, what work or training are you interested in?

    Do you have problems with
    Reading YesNo
    Understanding what you read YesNo
    Organisation YesNo
    Spelling YesNo
    Written Work YesNo
    Memory YesNo
    Note Taking YesNo
    Speeds in writing YesNo
    Learning information YesNo
    Numbers YesNo

    How do problems affect work, training or education?

    What are your concerns and view of these problems?

    What are the questions that you hope we can answer?