Full name
*
Date of birth
*
MM
DD
YYYY
Age
*
Country of birth
Date moved to UK (if applicable)
MM
DD
YYYY
Are you adopted?
Yes
No
Prefer not to say
How do you identify yourself?
Male
Female
Non binary
Prefer not to say
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Did you meet all the normal developmental milestones reached ?
Have you ever seen any other specialists (e.g. speech specialists) or been assessed for learning difficulties such as dyslexia?
Have you ever suffered from any serious illnesses?
Are you currently taking any medication?
ls your hearing within normal limits?
Have you had any history of visual difficulties/problems with sight/visual impairment?
What date did you last have a sight test by an optometrist (optician)?
Was any prescription made?
Do you wear prescribed glasses/contact lenses? If you do, please bring them with you to the assessment.
Have you ever used coloured overlays / colour-tinted glasses? If you are currently using coloured overlays/glasses, please bring them with you to the assessment.
At a screen ?
Reading books, newspapers or comics?
Has your screen /reading /near work time increased recently? If so, by how much?
Do you get headaches when reading?
Always
Often
Sometimes
Never
Does reading makes your eyes feel sore, gritty or watery?
Always
Often
Sometimes
Never
Does reading make you feel tired or sleepy?
Always
Often
Sometimes
Never
Do you become restless, fidgety or distracted when reading?
Always
Often
Sometimes
Never
Do you become less comfortable the longer you read?
Always
Often
Sometimes
Never
When do you prefer dim light to brighter light for reading?
Always
Often
Sometimes
Never
Does reading from white paper seem too bright or glaring?
Always
Often
Sometimes
Never
Do parts of the white page between the words form patterns when you read?
Always
Often
Sometimes
Never
Does the print or background shimmer or appear coloured as you read?
Always
Often
Sometimes
Never
Does print appear to jitter or move on the page as you read?
Always
Often
Sometimes
Never
Do you screw your eyes up when reading?
Always
Often
Sometimes
Never
Do you rub your eyes to relieve the strain when you are reading?
Always
Often
Sometimes
Never
Do you move your eyes around or blink to keep text clear when you are reading?
Always
Often
Somtimes
Never
Do you use a marker or your finger to stop you losing the place when you read?
Always
Often
Sometimes
Never
Do you cover or close one eye when reading?
Always
Often
Sometimes
Never
Do you lose your place when reading?
Always
Often
Sometimes
Never
Do you re-read or skip words or lines when reading?
Always
Often
Sometimes
Never
Does text appear blurred, or go in and out of focus, when you read?
Always
Often
Sometimes
Never
Do objects in the distance appear more blurred after you have been reading?
Always
Often
Sometimes
Never
Do the words, page or book appear double when you are reading?
Always
Often
Sometimes
Never
Please indicate whether any other family members experienced difficulties with reading/writing /spelling/general learning or were ever diagnosed with a Specific Learning Difficulty.
Is English your first language?
Which Secondary School did you attend?
What were the subjects you enjoyed and were good at ?
What were the subjects you were not so good at ?
How old were you when your difficulties were first noticed?
Did you have a good relationship with your teachers?
Yes
Neutral
No
Did you work as hard in school as you might have done?
Yes
Neutral
No
Did you have any specialist support at school?
Was your schooling disrupted in any way?
What qualifications did you leave school with?
Writing
None
Mild
Moderate
Severe
Spelling
None
Mild
Moderate
Severe
Mathematics
None
Mild
Moderate
Severe
Sports and Games
None
Mild
Moderate
Severe
If you are currently working, What is the name of your employer?
What is your current position?
Do you currently experience any difficulties at work?
Please give details of any previous work you have done?
Are you currently studying?
Where are you studying?
Is this part time or full time?
Please outline any difficulties you are experiencing with studying?
Have you taken any other courses since leaving school?
Please explain why you would like an assessment
Literacy
Please indicate the areas where you have problems:
Comprehension
Please indicate the areas where you have problems:
Listening Skills
Please indicate the areas where you have problems:
Writing
Please indicate the areas where you have problems:
Spelling
Please indicate the areas where you have problems:
Memory, Attention and Concentration
Please indicate the areas where you have problems:
Are there any situations when you do not feel confident or feel uncomfortable?
Do you have any difficulties developing good working relationships?
Do you have any difficulty developing friendships?
Yes
Neutral
No
Do you find it hard to make eye contact with people?
Yes
Neutral
No
Communication
Please indicate the areas where you have problems:
Number, Estimation and Calculation
Please indicate the areas where you have problems:
Motor Skills
Please indicate the areas where you have problems:
Strengths
Please outline any areas of strengths you have, what you enjoy doing in your spare time and things that you are good at etc.
Did you have any help to complete this form?
Do you receive assistance with day-to-day living, for example, from a carer?
Have you ever been told you have, or been diagnosed with, a learning disability, e.g. moderate learning difficulty, severe learning difficulty, or global learning difficulty?
Do you receive the Personal Independence Payment (PIP)?
Please summarise your difficulties and say if there is anything you would like help with in particular. Have any strategies worked for you so far? For example, when planning your work do you mostly think in pictures or words or both?
Any other information not covered within this form that we should know before the assessment
Signed
*
Dated
MM
DD
YYYY
