Screening

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Please answer the following questions regarding your child with yes, no, or I don’t know.

DYSLEXIA Screening

* Indicates required field

Name *

First

Last

Email *

Did your child have difficulty learning to tie their shoes? *

Yes No I Don't Know

Does your child lose their place frequently while reading and skip words or whole lines? *

Yes No I Don't Know

Does your child struggle with reading vowels and switch out the sounds? *

Yes No I Don't Know

Does your child seem very bright and intelligent, yet they are unable to read, write or spell at grade level? *

Yes No I Don't Know

Does your child frustrate easily when trying to read? *

Yes No I Don't Know

Do they have mix up the sounds or syllables when saying long words? *

Yes No I Don't Know

Do they have difficulty telling time on a traditional clock with hands? *

Yes No I Don't Know

Do they frequently misspell common high frequency words that other kids their age do not miss? *

Yes No I Don't Know

Are they told on many occasions that they are “lazy” or “not trying hard enough”? *

Yes No I Don't Know

Do they have trouble with handwriting…it varies or is illegible? *

Yes No I Don't Know

Do they often confuse directionality, for example left/right or over/under? *

Yes No I Don't Know

Does your child tend to be messy or unorganized? *

Yes No I Don't Know

Is their spelling inconsistent? For example, they get a good grade on a spelling test, but cannot carry spelling through to their writing. *

Yes No I Don't Know

Do they reverse letters or numbers past 7 yrs old or 1st grade? *

Yes No I Don't Know

When doing math memorizing math facts and reading word problems are difficult for your child? *

Yes No I Don't Know

Do they incorrectly copy notes from the board or a book to their paper? *

Yes No I Don't Know

Has someone in your family (father, mother, grandparent, aunt, uncle) been diagnosed with dyslexia or had similar reading difficulties? *

Yes No I Don't Know

Comment *

Phone Number *

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DESIGNED BY MRSCHERYM (c) 2017

Home
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Screening
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DYSLEXIA Screening

DESIGNED BY MRSCHERYM (c) 2017​

DESIGNED BY MRSCHERYM (c) 2017