A.

Name: ______________________________
Nationality:___________________________
Gender: _____________________________
Age: ________________________________
What languages can you speak? Please list all that apply.
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*Please check all that apply:*

I use English
____ at home ____ at school ____ with my friends ____ on the internet

B.
For each statement, please circle the number under the appropriate heading.
1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
English.

I am good at learning English. 1 2 3 4

I enjoy learning English. 1 2 3 4

I like to speak to others in English. 1 2 3 4

I want to improve my English. 1 2 3 4

I know a lot of things about English culture. 1 2 3 4

I want to know more about English culture. 1 2 3 4

C.
For each statement, please circle the number under the appropriate heading.
1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
Reading

1. When I read, I understand most of the words immediately. 1 2 3 4

2. I can guess the meanings of words I dont know 1 2 3 4

3. I can identify main ideas and supporting details. 1 2 3 4

4. I can read sentences and paragraphs quickly. 1 2 3 4

5. Its easy to talk about things Ive read. 1 2 3 4

6. I often read in English in my spare time. 1 2 3 4

Listening
7. I can identify the topic of listening exercises. 1 2 3 4

8. I can follow spoken instructions well. 1 2 3 4

9. I can understand English spoken with different accents. 1 2 3 4

10. I can understand native speakers speaking quickly. 1 2 3 4

11. Its easy to follow conversations in English. 1 2 3 4

12. I often watch TV / listen to the radio in English. 1 2 3 4

Grammar
13. I like learning grammar by learning rules. 1 2 3 4

14. I like learning grammar by looking at examples. 1 2 3 4

15. I can use grammatically correct sentences without thinking

carefully about the rules. 1 2 3 4

16. I understand the grammar of texts I read. 1 2 3 4

17. I want my teachers to explain grammar rules. 1 2 3 4

18. I can understand the meaning of a sentence even if I dont

understand the grammar rules. 1 2 3 4

Writing

19. I can organize information in a paragraph. 1 2 3 4

20. I can give good reasons and examples. 1 2 3 4

21. I can write sentences and paragraphs quickly. 1 2 3 4

22. I can support my ideas with clear details and

examples. 1 2 3 4

23. I am interested in the topics I write about in class.

24. I can write definitions of words easily. 1 2 3 4

D.

What subjects are you interested in?

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What do you like to do in your spare time?

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What kinds of activities do you like to do in class?

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What kinds of activities do you not like to do in class?

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What do you prefer to study in class? Why?

(Reading / Writng/ Grammar / Speaking)

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