Pre-Assessment Questionnaire Student

* Denotes required field

1. First Name*
Last Name*
2. Child's Name
3. Address*
Address Line 1*:
Address Line 2:
Post Code/Zip Code*:
4. Telephone*
5. Email address*
Date of Birth*
6. Year Level (if relevant)
7. Teachers Name
8. Crawled on time: YesNo
Walked 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?

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?
Have a shadow
White part stands out more than words
Static/large shading behind groups of words or parts of the page

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?
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)
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 given
more 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.

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
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.
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