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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?
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Yes
No
I Don't Know
Does your child lose their place frequently while reading and skip words or whole lines?
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Yes
No
I Don't Know
Does your child struggle with reading vowels and switch out the sounds?
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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?
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Yes
No
I Don't Know
Does your child frustrate easily when trying to read?
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Yes
No
I Don't Know
Do they have mix up the sounds or syllables when saying long words?
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Yes
No
I Don't Know
Do they have difficulty telling time on a traditional clock with hands?
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Yes
No
I Don't Know
Do they frequently misspell common high frequency words that other kids their age do not miss?
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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?
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Yes
No
I Don't Know
Do they often confuse directionality, for example left/right or over/under?
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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?
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Yes
No
I Don't Know
When doing math memorizing math facts and reading word problems are difficult for your child?
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Yes
No
I Don't Know
Do they incorrectly copy notes from the board or a book to their paper?
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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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