Name

Date of Birth

School

Class

Name of person filling form

Relationship to child

Reading & Spelling
When the pupil/student reads and spells, does s/he frequently:

Confuses letters that look similar: d - b, u - n, m – n? YesNo

Confuses letters that sound the same: v, f, th? YesNo

Reverses words: was - saw, now – won? YesNo

Transposes words: left - felt? YesNo
Reads a word correctly and then further down the page, read it wrong? YesNo

Changes words around: the cat sat on the mat (the mat sat on the cat)? YesNo

Confuses small words: of, for, from? YesNo

When reading, has difficulty in keeping the correct place on a line and frequently loses his/her place? YesNo

Reads correctly but does not understand what s/he is reading? YesNo

Writing
Even after frequent instruction, does s/he still:

Not know whether to use his/her right or left hand? YesNo

Leaves out capital letters or use them in the wrong places? YesNo

Forgets to dot the ‘i’s, and cross ‘t’s? YesNo

Forms letters and numbers badly? YesNo

Slopes his/her writing on the page? YesNo

Uses punctuation and paragraphs in the wrong places, or not at all? YesNo

Other Indicators

Is there a family history of dyslexia or similar difficulties? YesNo If yes, please indicate who.

Was s/he a late developer? YesNo If yes, please indicate in what areas.

Is s/he easily distracted and has poor concentration? YesNo

Does s/he have an awkward head tilt while reading? YesNo

Does s/he squint the eyes while reading or copying things from the board? YesNo

Does s/he have hearing problems? YesNo

Does s/he get confused between: left/right, east/west, up/down, over/under? YesNo

Does s/he hold a pen too tightly and awkwardly? YesNo

Does s/he have problems telling the time? YesNo

Does s/he have problems with tying shoe laces, etc? YesNo

Does s/he have short-term memory problems relating to printed words and instructions? YesNo

Does s/he have mixed laterality (i.e. uses either right or left hands or eyes, in writing and other tasks)? YesNo

Does s/he have particular difficulty copying from a blackboard? YesNo

Does s/he have confusion with mathematical symbols (plus/minus, etc)? YesNo

Does s/he have inability to follow more than one instruction at a time? YesNo

Can s/he use a dictionary or telephone directory? YesNo

Does s/he have sequencing difficulties in reciting the:
Alphabet? YesNo
Nursery rhymes? YesNo
Months of the year? YesNo
Numbers in multiplication tables? YesNo

Is s/he clumsy or has poor body coordination? YesNo

Strengths

Does s/he have good verbal skills – like to talk or tell stories? YesNo

Is s/he good in drawing or painting or sketching? YesNo

Is s/he good with her/his hands, for e.g. fixing or repairing things, like to work with tools, etc YesNo

Is s/he always full of ideas about various things? YesNo

Do you think the child is creative? YesNo

Do you think the child has a high sense of curiosity and wants to know about things? YesNo

Do you think the child has good general knowledge? YesNo