Child's full name
*
Child's date of birth
*
MM
DD
YYYY
School year
*
Country of birth
Date moved to UK (if applicable)
MM
DD
YYYY
Is the child adopted?
Yes
No
Prefer not to say
How does the child identify themselves?
Male
Female
Non binary
Prefer not to say
Title and full name of Parent/Carer
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Did you experience any problems during the pregnancy or birth of your child?
Were all the normal developmental milestones reached ?
Has your child ever had any Speech and Language difficulties?
Is there a history of ear infections, glue ear or grommets?
Has your child had any history of visual difficulties/problems with sight/visual impairment?
Does your child wear glasses?
Has your child 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 child’s screen /reading /near work time increased recently? If so, by how much?
Does your child report headaches when reading
Always
Often
Sometimes
Never
Does your child report that reading makes their eyes feel sore, gritty or watery?
Always
Often
Sometimes
Never
Does your child report feeling tired or sleepy during or after reading?
Always
Often
Sometimes
Never
Have you noticed your child become restless, fidgety or distracted when reading?
Always
Often
Sometimes
Never
Have you noticed your child rubbing their eyes when they are reading?
Always
Often
Sometimes
Never
Have you noticed your child screwing up their eyes when reading?
Always
Often
Sometimes
Never
Have you noticed your child tilting their head to one side when reading?
Always
Often
Sometimes
Never
Have you noticed your child moving their eyes around or blinking frequently when they are reading?
Always
Often
Sometimes
Never
Have you noticed your child holding a paper or book very close to their eyes when reading?
Always
Often
Sometimes
Never
How often does your child use a marker or their finger to keep their place when reading?
Always
Often
Sometimes
Never
Have you noticed that your child frequently loses their place when reading?
Always
Often
Sometimes
Never
Have you noticed your child covering or closing one eye when reading?
*
Always
Often
Sometimes
Never
When you read, do you see two of each word?
Always
Often
Somtimes
Never
When you read, do the words you read look blurry (or fuzzy, or unclear)?
Always
Often
Sometimes
Never
When you are reading, do the words move on the page?
Always
Often
Sometimes
Never
When your teachers ask you to copy something from a screen at the front of the classroom, can you see what is written on the screen?
Always
Often
Sometimes
Never
ls your child’s hearing within normal limits?
Is your child on any regular medication that may be relevant?
Please indicate whether any other family members experienced difficulties with reading/writing /spelling/general learning or were ever diagnosed with a Specific Learning Difficulty.
Are any other languages spoken at home?
Did your child pass the Phonics Test?
Has your child’s schooling been disrupted in any way?
Have any of your child’s teachers discussed any difficulties your child is experiencing?
Has your child seen any other specialists (e.g. Educational Psychologist, Advisory teacher etc)?
Has your child received any support or intervention in the past?
English
Maths
Reading
None
Mild
Moderate
Severe
Writing
None
Mild
Moderate
Severe
Spelling
None
Mild
Moderate
Severe
Mathematics
None
Mild
Moderate
Severe
Sports and Games
None
Mild
Moderate
Severe
Is there any specialist help currently given at school?
Is your child currently receiving any tuition outside of school?
Please describe your child’s current strengths and difficulties with Literacy?
Does your child have difficulty recalling the alphabet or other known sequences?
Please describe your child’s current strengths and difficulties with Numeracy?
Does your child have difficulty telling the time?
Does your child have difficulties with memory, attention or concentration?
Are there any current difficulties with speech, oral language or communication?
Does your child have difficulties with social skills, behaviour, peer relationships or emotional adjustment?
Does your child have difficulties with self-esteem and confidence?
Does your child have good organisational skills?
Does your child have any difficulties with fine and gross motor skills e.g. body awareness, movement and balance?
Does your child experience left/right confusion?
Please provide information about your child’s strengths, what they are good at, hobbies they enjoy etc.
Any Other Information
Signed
*
Relationship to child
