Pre-Assessment Questionnaire Student * Denotes required field 1. First Name* Last Name* 2. Child's Name 3. Address* Address Line 1*: Address Line 2: City/Town*: Country*: Post Code/Zip Code*: 4. Telephone*Mobile 5. Email address*Date of Birth* 6. Year Level (if relevant) 7. Teachers Name 8. Crawled on time: YesNoWalked on time: YesNo 9. Any developmental hearing problems? If yes please explain YesNo 10. Reading a. What type of reading does your child do? (Example - novels, cartoons, study guides.) b. Or do they prefer not to read at all? YesNo c. Are they able to remember what they have read? d. How many times would your child need to re-read material to answer questions about it? e. What do the words look like on the page when they 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 11. Spelling a. What is their spelling like? b. Are they able to retain spelling words they have studied over time?c. Do they forget the spelling words if they stop studying them? 12.Transcriptions a. When your child is copying from a book or whiteboard are they able to: Remember a whole sentence at a time? Yes Or just a few words before they need to look back? Yes b. How many words are they able to remember? c. Are they able to copy quickly? YesNo d. Are they able to copy accurately? YesNo 13. Writing a. When writing, do they use: Capital Letters (PRINT) Joined letters (cursive) Neither b. Do they reverse letters or numbers? YesNo c. Are they able to write in a straight line without guidelines? YesNo d. Do they confuse left and right? YesNo 14. Behaviour a. Is your child's behaviour unsettled or fidgety? YesNo b. Do they find it hard to concentrate? YesNo c. Do they get stressed or upset because they are unable to do English or Maths task? YesNo d. Do they ever call themselves "dumb","stupid", and say "I just can't do it" YesNo 15. Instructions a. Do they find it difficult to remember instructions if they are givenmore than 1 or 2 at a time? YesNo b. Do they prefer to have instructions written down,simple and/or in print form? YesNo 16. Maths a. Which of their times table do they know? b. Are maths comprehension questions difficult to understand? YesNo c. Can they tell time? YesNo 17. Eyes a. Do they get sore eyes/headaches if they 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 they last have their eyes checked by an Optician?* c. What were the results? d. If they wear glasses what is the prescription? e. Do they have a turned eye? (If you are unsure ask your Optician)* YesNo 18. General Information a. Are they on medication that could impact on their ability to learn? b. Have you ever taken them to an Ophthalmologist (eye surgeon)? YesNo c. If yes, provide details. Please fill the required field. d. What is their general health like? e. Have they had any surgery or falls that would impact on their ability to learn?* YesNo f. Have they had any of the following to assist with learning? (select as many as apply) Occupational Therapy Speech Therapy Physiotherapy Tutoring Other g. Do they have epilepsy?* YesNo h. Have they had any education/pyschological testing done? i. If so, please send a copy of the report/s with this questionnaire prior to their initial assessment. Max: 7MB Please list any other comments, concerns or other relevant information you feel we should know below. j. How did you hear about us?* Google AdWordGoogle SearchAbsolutely EducationAbsolutely MagazineBath MagazineYummy Mummy MagazineSherborne TimesIndependent School Parent MagazineIndependent Schools ShowA+ Education SupplimentDyslexic Schools WebsiteFacebook AdvertTwitter AdvertLinkedIn AdvertGoogle+ AdvertFriendOther 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 By completing this form, you are agreeing that ALC will also occasionally send you subscription, editorial, marketing and research email messages, but you will always have the opportunity to opt-out of these message. We promise never, ever to pass your details on to third parties.
