Am I Dyslexic Form 1 Please check all that apply* Denotes required field General 1. Appears: Bright Highly intelligent Articulate but unable to: Read at grade level Write at grade level Spell at grade level 2. Labelled: Lazy Dumb Careless Immature Not trying hard enough Has behaviour problems 3. Feels dumb Has poor self-esteem Hides or covers up weaknesses within ingenious compensatory strategies Is easily frustrated and emotional about school reading or testing 4. Difficulty sustaining attention Appears hyper or daydreams Vision, Reading, and Spelling 5. While reading complains of: Dizziness Headaches Stomach aches Sore eyes 6. Reading or writing shows: Repetitions Additions Transpositions Omissions Substitutions Reversals 7. Complains of feeling or seeing non-existent movement while Reading Writing Copying 8. Seems to have difficulty with vision, yet no need for glasses. 9. Extremely keen sighted and observant Lacks depth of perception and peripheral vision 10. Difficulty in understanding and remembering what has been read. 11. Spells phonetically and inconsistently. 12. Dislikes reading.