DYSLEXIA SCREENING FORM

General Information
1. 2. 3. 4. 5. 6. Is there anything in your medical history that could explain your difficulties? YES YES YES YES YES YES NO NO NO NO NO NO If so, what? If so, what? If so, when. If so, please describe. If so, when If so, please describe. Last hearing examination? Did you always had academic difficulties? Did you have an eye examination? Do you have any eyesight problems? Did you have a hearing examination? Do you have any hearing problems?

General Indications of Dyslexia

1. Did someone in your family have reading, writing and/or speaking difficulties? YES YES YES YES YES NO NO NO NO NO If so, what? If so, when. If so, please describe. If so, please describe. If so, at what age. Last hearing examination? 2. Do you have a central auditory processing problem? 3. Did you have tubes in your ears? 4. Do you have difficulty hearing what people say? 5. Did you have repeated ear infections? 6. Do you have an average or above average IQ but not doing do well academically or on tests/interviews? YES YES NO NO 7. Are you forgetful?

2005 Canadian Dyslexia Centre (CDC) Inc.

DYSLEXIA SCREENING FORM

8. Do you have difficulty concentrating? YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 9. Do you have good days and bad days? 10. Do you have poor articulation? 11. Do you feel that the other person dont get the big picture or just dont get it? 12. Do you have difficulty in getting out what you want to say? 13. Are you all over the place when answering question? 14. Do you use mainly simple sentence structure? 15. Do you use incorrect sentence structure? 16. Do you feel that some persons go on and on when speaking? 17. Have some persons told you that you go on and on when speaking? 18. Do you have at tendency to forget names of common objects and people? 19. Do you have difficulty answering a question on a specific subject within a time limit? 20. Do you often omit words when speaking? 21. Do you often mispronounce words when speaking? 22. Do you often misuse words when speaking? 23. Do you finish your sentences when speaking?

2005 Canadian Dyslexia Centre (CDC) Inc.

DYSLEXIA SCREENING FORM

24. Do you often confuse syllables in speech amulinum, sghapetti? YES YES YES YES YES YES YES YES YES YES YES YES YES LEFT LEFT NO NO NO NO NO NO NO NO NO NO NO NO NO RIGHT RIGHT I DONT KNOW EITHER 25. Do you often forget what you were going to say? 26. Do you finish your sentences when speaking? 27. Do you forget to proof read your examination paper? 28. Do you take an inordinate time to write a term/essay paper? 29. Do you lack of organisation in notes? 30. Do you often misread examination questions? 31. Do you have difficulty understanding your own notes? 32. Do you have difficulty sticking to the question? 33. Do you suffer from extreme stress during examinations/interviews? 34. Do you often feel that you can read someones mind? 35. Do you find difficulty in telling left from right? 36. Are you left-handed? 37. Which foot do you use to kick a ball? 38. If you look though a tube, like a telescope, which eye do you use?

2005 Canadian Dyslexia Centre (CDC) Inc.

DYSLEXIA SCREENING FORM

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 YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO If yes, how many times? 41. Do you find it difficult to say the months of the year backward? 42. Do you have difficulty following a sequence of verbal instructions? 43. Are you known to be clumsy? 44. Do you mix up dates and times and miss appointments? 45. Do you have a poor sense of direction, do you get lost easily? 46. Do you tend to get telephone numbers mixed up when you dial? 47. Do you find it difficult to take messages on the telephone? 48. Did you or do you find it hard to learn your multiplication tables? 49. Did you or do you have difficulty learning to tell time? 50. Do you often mix up numbers like 67 and 76, or 234 and 423? 51. Do you often make mistakes when writing checks/cheques? 52. Did you change school often? 53. Did you study hard at school, but had poor results on tests?

2005 Canadian Dyslexia Centre (CDC) Inc.

DYSLEXIA SCREENING FORM

54. Did you often miss school? YES YES YES YES YES YES YES YES YES YES YES YES YES 67. Do you read? YES YES YES NO NO NO 68. Do you change words when reading - lamp for light, kitchen for chicken? 69. Do you guess at the words? NO NO NO NO NO NO NO NO NO NO NO NO NO If so, please describe. If so, please describe. If so, please describe. If so, please describe. If no, please describe. If yes, explain. If yes, please say in what grade and explain. If yes, please say in what grade and explain. If yes, please say in what grade and explain. If yes, please say in what grade and explain. 55. Do you remember being afraid to go to school? 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? 60. Do you remember feeling frustrated at school? 61. Do you perform better orally than in writing on tests? 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?

2005 Canadian Dyslexia Centre (CDC) Inc.

DYSLEXIA SCREENING FORM

70. Do you read by sounding out words? YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 71. Do you read slowly? 72. Is your reading choppy? 73. Do you have difficulty reading aloud? 74. Does it take you a long time to read a page in a book? 75. Do you often reread sentences? 76. Do you often forget how to spell words? 77. Do you see the word written in your head? 78. Do you usually spell a word by the way its sounds? 79. Do you have difficulty planning and organizing essays? 80. Do you have difficulty with punctuation? 81. Do you have difficulty knowing when to start or finish a paragraph? 82. Do you have difficulty with grammar and syntax? 83. Is your handwriting slow and messy? 84. Do you have difficulty putting your thoughts down on paper? 85. Do you often have headaches when reading?

2005 Canadian Dyslexia Centre (CDC) Inc.

DYSLEXIA SCREENING FORM

86. Do you sometimes see white lines, rivers or patterns in printed text? YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO If so, please describe. If so, please describe. If so, please describe. If so, please describe. If so, please describe. If so, please describe. If so, please describe. 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? 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? 94. Do you have difficulty copying from the board? 95. Do you have difficulty taking notes at speed? 96. Do you find it difficult and confusing to fill out forms? 97. Do you dislike reading instructions?

2005 Canadian Dyslexia Centre (CDC) Inc.