Dyslexia Screening Questionnaire

Once you submit this form we will make contact with you and arrange what to do next.

You can also download the Dyslexia Screening Questionnaire as a Word document to print out and return to us.

Name *

Student number *
Address *
Telephone
Email address *
Date of birth (DD/MM/YYYY) *
Course *
Year of study *
Tutor *
Have you been screened or tested before? *
If yes, what was the outcome?
* Required Field

Background health history
Please tick which of the following you have experienced:

Ear infections
Speech/language difficulties
Vision problems
Allergies/asthma
Clumsy/co-ordination problems
Missed developmental milestones
Do any of your family experience similar problems, or have they been diagnosed with specific learning difficulties (dyslexia, etc)?
Other comments on health

Primary school
Please tick if any of the following are relevant to your experience of primary school:

Problems learning to read
Received extra help
Second language interferences
Disruptions / missed school
Problems/delays in learning to tell the time, tie shoelaces, catch a ball, ride a bike
Other comments on primary school experience

Secondary school/sixth form
Please tick if any of the following are relevant to your experience of secondary school/sixth form:

Problems recognised by school
Received extra help
Received extra time in exams
Disruptions / missed school
Attitude of teachers/their comments:
Other comments on secondary school experience:

Please tell us about your educational experiences since leaving school:
What are your educational aims?
Self-assessment of difficulties:

Language / listening
Please tick if you experience any of the following:

Trouble listening
Trouble concentrating with background noise
Word retrieval problems
Problems listening and taking notes at the same time
Pronunciation difficulties
Comments

Reading
Please tick if you experience any of the following:

Need to re-read frequently
Difficulties reading out loud
Comprehension difficulties
Word recognition difficulties
Print 'dances', blurs or irritates eyes
Comments

Spatial / temporal
Please tick if you experience any of the following:

Map reading difficulties
Left/right confusion
Get lost easily
Difficulties following verbal instructions
Comments

Writing and spelling
Please tick if you experience any of the following:

Difficulties getting ideas down on paper
Word finding difficulties
Problems with grammar / sentence structure
Problems planning and organising work
Difficulties remembering what words look like
Difficulties telling the difference between sounds
Comments

Maths
Please tick if you experience any of the following:

Difficulties memorising tables
Difficulties with long division
Difficulties remembering basic number facts
General maths difficulties
Can’t use bus/train timetables
Comments

Memory difficulties
Please tick if you experience any of the following:

Problems remembering the alphabet
Erratic memory
Problems with months/days/seasons
Difficulties remembering names/dates/facts
Forget telephone numbers
Other
Comments

Visual motor
Please tick if you experience any of the following:

Copying difficulties
Difficulties controlling pen
Letter reversals
Irregular/awkward letter construction
Unusual paper position
Problems with writing what’s intended
Unusual pen grip
Hand gets tired after short period of writing
Left handed
Other
Comments