Pre-Assessment Questionnaire


 

 

* Denotes required field

1. First Name*
Last Name*
2. Mobile
Date of Birth*
Email Address*
3. Address*
Address Line 1*:
Address Line 2:
City/Town*:
Country*:
Post Code/Zip Code*:
4. Did you have any hearing problems when you were growing up? If yes please explain YesNo
5. Reading
a. What type of reading do you do?
(Example - novels, cartoons, news, study guides)
b. Or do you prefer not to read at all?
YesNo

c. Are you able to remember what you have read?
d. How many times would you need to re-read material to answer questions about it?
e. What do the words look like on the page when you are trying to read?
Fuzzy
3D
Have a shadow
White part stands out more than words
Static/large shading behind groups of words or parts of the page
Other

6. Spelling
a. What is your spelling like?
b. Are you able to retain spelling words you have studied over time?
c. Do you forget the spelling words if you stop studying them?
7. Transcriptions
a. When you are copying from a book or whiteboard are you able to:
Remember a whole sentence at a time? Yes
Or just a few words before you need to look back? Yes
b. How many words are you able to remember?

(*If you are not sure try copying this to a sheet of paper and see what happens.)

c. Are you able to copy quickly? YesNo
d. Are you able to copy accurately? YesNo
8. Writing
a. When writing, do you use:
Capital Letters (PRINT)
Joined letters (cursive)
Neither
b. Do you reverse letters or numbers? YesNo
c. Are you able to write in a straight line without guidelines? YesNo
d. Do you confuse left and right? YesNo
9. Behaviour
a. Is your behaviour unsettled or fidgety? YesNo
b. Do you find it hard to concentrate? YesNo
c. Do you get stressed or upset because you are unable to do a task? YesNo
d. Do you ever call yourself 'dumb', 'stupid', and say "I just can't do it" YesNo
10. Instructions
a. Do you find it difficult to remember instructions if you are given
more than 1 or 2 at a time? YesNo
b. Do you prefer to have instructions written down,
simple and/or in print form? YesNo
11. Maths
a. Which of your times table do you know?

b. Are maths comprehension questions difficult to understand? YesNo
c. Can you tell time? YesNo
12. Eyes
a. Do you get sore eyes/headaches if you read/write for a long time?
Sore eyes when reading
Headaches when reading
Watery eyes when reading
Sore eyes when writing
Headaches when writing
b. When did you last have you eyes checked by an Optician?*
c. What were the results?
d. If you wear glasses what is the prescription?
e. Do you have a turned eye? (If you are unsure ask your Optician)* YesNo
13. General Information
a. Are you on medication that could impact on your ability to learn?
b. Have you been to an Ophthalmologist (eye surgeon)? YesNo
c. If yes, provide details.

d. What is your general health like?
e. Have you had any surgery or falls that would impact on your ability to learn?* YesNo
f. Did you think or know you had learning difficulties while at school? YesNo

If Yes, did you have any of the following?
Occupational Therapy
Speech Therapy
Physiotherapy
Tutoring
Other

g. Do you have epilepsy?* YesNo
h. How did you hear about us?*
I understand that all treatment carried out will be in accordance with the Terms of Supply as shown on this website, which I agree to I understand that all treatment carried out will be in accordance with the Terms of Supply as shown on this website, which I agree to
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