*** ONLY ANSWER THE QUESTIONS IN THIS SECTION THAT YOU ARE COMFORTABLE ANSWERING. IT WILL NOT IMPACT YOUR REPORT IF THESE QUESTIONS ARE OMITTED.
HERE ARE YOUR 125 QUESTIONS :
1. Has the student had an eye exam within the last year?
2. Do you feel the student has, or may have, difficulty hearing?
3. Has the student been seen by a physician for a physical within the past year?
4. Does the student have any dental issues that may be affecting their educational performance?
5. Is the student easily distracted during learning activities?
6. Does the student have, or is it suspected that they may have, a medical condition which affects learning performance?
7. Does a close relative, such as the student's parent, grandparent, brother, or sister have a learning disability or serious medical condition?
8. Is the student presently taking any medications?
9. Does the student get enough sleep?
10. Is the student often hungry during learning times?
11. Does the student have adequate and consistent times to study, during the day?
12. Is the student able to stick to a homeschooling schedule, with consistent daily times devoted to specific academic areas?
13. Does the student refuse to do their assignments?
14. Does the student tend to begin class without the necessary books and materials?
15. Does the student avoid doing, or not hand in, their homework assignments? If the student is not assigned homework assignments at their grade level, click "Not Applicable".
16. Does the student require excessive time to complete homework assignments?
17. Does the student have difficulty sounding out new words that are appropriate for their age/grade level?
18. Does the student have difficulty recognizing words that are common for their age/grade level?
19. Does the student have difficulty understanding the meaning of words that are common for their age/grade level?
20. After reading a passage that should be appropriate for their age/grade level, does the student have difficulty understanding what has been read?
21. Does the student tend to confuse similar letters, such as…
b..........d
b..........q
b..........p
b..........g
p..........q
p..........g
p..........d
g..........q
g..........d
d..........q
m..........w
n..........u
or similar looking letter sets?
22. Does the student tend to confuse words with similar letters, such as....
saw..........was
how..........who
won..........now
or other sets of words with similar letter combinations?
23. Does the student experience any of the following?
The student prefers to read in dim lighting.
Florescent lighting makes the letters on a page move, strobe, blur, or change.
After reading for a time, the letters on a page move, strobe, blur, or change.
After reading for a time, the letters on a page either rise up or sink into the page.
After reading for a time, flashing light is observed in the white spaces on the page.
24. When reading out loud, does the student tend to leave out and/or add words?
25. When reading material at the student's reading level, does the student tend to read too quickly as to miss the meaning of the passage, or too slowly, taking too much time to complete a reading passage? If the student is reading either too quickly or too slowly, answer "yes". If the student is reading at an appropriate speed, answer "no".
26. Does the student tend to read for enjoyment?
27. Which method is easiest for the student to learn a new word?
a) Seeing the new word on an index card, until it is learned.
b) Listening to and replaying a tape, where the student hears the word and its letters, until it is learned.
c) Writing the word over and over again, until it is learned.
d) Prefers to do a combination of the above activities, until it is learned.
28. Does the student know their addition math facts (adding two single digit numbers)? Examples of this might be 3 + 4 = ?, 7 + 9 = ?, etc. If the student is younger than first grade, click "not applicable".
29. Does the student know their subtraction math facts (subtracting two numbers where the second number is a single digit, and getting a single digit answer)? Examples of this might be 9 - 4 = ?, 18 - 9 = ?, etc. If the student is younger than first grade, click "not applicable".
30. Does the student know their multiplication math facts (multiplying two single digit numbers)? Examples of this might be 3 x 4 = ?, 7 x 9 = ?, etc. If the student is younger than third grade, click "not applicable".
31. Does the student know their division math facts (dividing either a one or two digit number by a one digit number, getting a one digit number as the answer)? Examples of this might be 12 ÷ 4 = ?, 8 ÷ 2 = ?, etc. If the student is younger than third grade, click "not applicable".
32. Does the student tend to confuse similar numbers, such as…
6 and 9 or
2 and 5 or
similar looking number sets?
33. Does the student ever confuse numbers with similar numeric combinations, such as....
25 and 52
263 and 632
9443 and 9434
or other sets of numbers with similar numeric combinations?
34. Does the student ever make math calculation mistakes because they confuse the following math process signs?
+ - × ÷
35. Does the student have difficulty calculating addition problems that are common for their grade level? This question deals with adding whole numbers, rather than decimals or fractions.
36. Does the student have difficulty calculating subtraction problems that are common for their grade level? This question deals with subtracting whole numbers, not decimals or fractions.
37. Does the student have difficulty calculating multiplication problems that are common for their grade level? This question deals with multiplying whole numbers, not decimals or fractions. If the student is younger than third grade, click "not applicable".
38. Does the student have difficulty calculating division problems that are common for their grade level? This question deals with dividing whole numbers, not decimals or fractions. If the student is younger than third grade, click "not applicable".
39. Does the student have difficulty answering math problems involving fractions, which are common for their grade level? If the student is not working with fractions at their grade level, click "not applicable".
40. Does the student have difficulty answering math problems involving decimals, which are common for their grade level? If the student is not working with decimals at their grade level, click "not applicable".
41. Does the student have difficulty answering math problems involving numeric patterns, which are common for their grade level? An example might be: 2, 4, 6, 8, __, 12, where the student is asked to fill in the blank. The complexity of the pattern differs from grade level to grade level. If the student is not working with numeric patterns at their grade level, click "not applicable".
42. Does the student have difficulty answering math problems involving geometry, which are common for their grade level (a kindergarten student may be learning shapes, an elementary student may be calculating perimeters, a junior high student may be working with volumes, and a high school student might be solving theorems)? If the student is not working with geometry at their grade level, click "not applicable".
43. Does the student have difficulty answering math problems when the student is required to solve the problem in their head without pencil and paper (simple math problems common for their grade level)? If the student is not working with mentally computing math problems at their grade level, click "not applicable".
44. Does the student have difficulty answering math problems involving word problems, which are common for their grade level? An example of a word problem would be a situation described in sentence form, which requires some form of math computation to solve it (an example of a first grade word problem might be: Emily has three balloons. Sarah gives her two balloons. How many balloons does Emily have now?). If the student is not working with word problems at their grade level, click "not applicable".
45. Does the student have difficulty answering math problems involving the interpretation of data, graphs, or charts, which are common for their grade level? If the student is not working with math problems involving the interpretation of data, graphs, or charts at their grade level, click "not applicable".
46. Does the student have difficulty answering math problems involving estimating, which are common for their grade level? If the student is not working with math problems involving estimation at their grade level, click "not applicable".
47. Does the student have difficulty answering math problems involving measurement, which are common for their grade level? If the student is not working with math problems involving measurement at their grade level, click "not applicable".
48. Is the student able to tell time using a standard clock with hands? If the student is too young to have mastered this skill at their current grade level, click "not applicable".
49. When telling time, does the student use the terms "quarter after", "half past", and "quarter of" correctly? If the student is too young to have mastered this skill at their current grade level, click "not applicable".
50. Looking at any given time on a clock with hands, is the student able to tell how many minutes until the minute hand reaches the twelve (the o'clock position)? For example, if it is 2:43, does the student know it is 17 minutes before 3:00? If the student is too young to have mastered this skill at their current grade level, click "not applicable".
51. Is the student able to calculate the amount of time between two given times? For example, when asked how much time would transpire between 1:23 a.m. and 4:36 a.m., the student would know 3 hours and 13 minutes would have passed. If the student is too young to have mastered this skill at their current grade level, click "not applicable".
52. Does the student have a "sense of time" (time differentiation)? In other words, can the student identify the time one might eat dinner, the time one might get ready for school, etc.? Without looking at a clock, can the student estimate within reason the current time of day based upon the activities they have experienced? If the student is too young to have mastered this skill at their current grade level, click "not applicable".
53. Does the student have difficulty understanding the value of given sets of coins and/or bills, which are common for their grade level? If the student is not working with understanding the value of money at their grade level, click "not applicable".
54. Does the student have difficulty calculating the amount of change owed in given situations, which are common for their grade level? If the student is not working with calculating change (money) at their grade level, click "not applicable".
55. Does the student have difficulty answering questions based upon the use of a calendar, which are common for their grade level? If the student is not working with "calendar questions" at their grade level, click "not applicable".
56. If the student is in either junior or senior high school, does the student have difficulty answering math problems that are common for their grade level? If the student is not in junior or senior high school, click "not applicable".
57. Which method is easiest for the student to learn new math information?
a) Seeing the math information on an index card, until it is learned.
b) Listening to and replaying a tape, where the student hears the math information, until it is learned.
c) Writing the math information over and over again, until it is learned.
d) Prefers to do a combination of the above activities, until it is learned.
58. Does the student have difficulty writing words, sentences, or paragraphs, which are common for their grade level? A kindergarten student may be writing their name, a first grader may write a simple sentence, a second grader may write more complex sentences, a junior high student may be writing persuasive arguments, etc. If the student is not working with written expression activities at their grade level, click "not applicable".
59. Does the student have difficulty using grammar, common for their grade level? If the student is not working with grammar at their grade level, click "not applicable".
60. Does the student have difficulty with the rules for capitalization common for their grade level? This means that the student knows when to capitalize a word when writing sentences. If the student is not working with capitalization at their grade level, click "not applicable".
61. Does the student have difficulty with the rules for punctuation common for their grade level? This means that the student knows how to punctuate written sentences. If the student is not working with punctuation at their grade level, click "not applicable".
62. Does the student have difficulty spelling words that are common for their grade level? If the student is too young to work with spelling skills at their current grade level, click "not applicable".
63. Which method is easiest for the student to learn new spelling words?
a) Seeing the spelling word on an index card, until it is learned.
b) Listening to and replaying a tape where the student hears the spelling word and how it is spelled, until it is learned.
c) Writing the spelling word over and over again, until it is learned.
d) Prefers to do a combination of the above activities, until it is learned.
64. Does the student have difficulty with Social Studies? If the student is not working with Social Studies activities at their grade level, click "not applicable".
65. Which method is easiest for the student to learn new Social Studies information?
a) Seeing the Social Studies facts on index cards, until it is learned.
b) Listening to and replaying a tape where the student hears the Social Studies information, until it is learned.
c) Writing the Social Studies information over and over again, until it is learned.
d) Prefers to do a combination of the above activities, until it is learned.
66. Does the student have difficulty with Science? If the student is not working with Science activities at their grade level, click "not applicable".
67. Which method is easiest for the student to learn new Science information?
a) Seeing the Science facts on index cards, until it is learned.
b) Listening to and replaying a tape where the student hears the Science information, until it is learned.
c) Writing the Science information over and over again, until it is learned.
d) Prefers to do a combination of the above activities, until it is learned.
68. Is the student able to print legibly, as appropriate for their grade level? Can their printed handwriting be read? If the student is too young or physically unable to print legibly, click "not applicable".
69. Is the student able to write in script (cursive) legibly, as appropriate for their grade level? Can their script (cursive) handwriting be read? If the student is too young or physically unable to write in script (cursive) legibly, click "not applicable".
70. If the student needs to improve their handwriting, answer this question. If the student does not need handwriting help, click "not applicable".
Which method is easiest for the student to learn handwriting?
a) Seeing the letter and how it is formed, until the letter is learned.
b) Listening to someone explain the way you write the letter, until it is learned.
c) Writing the letter over and over again, until the letter is learned.
d) Prefers to do a combination of the above activities, until the letter is learned.
71. Does the student have difficulty copying from a chalkboard, even though they can see the board?
72. Does the student have difficulty copying letters/words/etc. from the top of a page of paper to the bottom of the page, even though they can see the letters/words/etc. on the piece of paper?
73. Does the student have difficulty telling the difference between similar looking shapes, words, or numbers as appropriate for their grade level? Some examples might be asking the student to find the different items in the following lines:
Does the student have difficulty with these types of problems as appropriate for their grade level?
74. Does the student have difficulty remembering a single shape or design as appropriate for their grade level? An example might be showing the student one geometric design on an index card for a few seconds (the amount of time depends upon the student's grade level). The design is then removed. A few seconds later the student is asked to remember that design and find it out of three or four similar looking choices (only one being the correct answer). Does the student have difficulty with these types of problems as appropriate for their grade level?
75. Does the student have difficulty remembering the order of a set of objects, pictures, letters, numbers, shapes, symbols, designs, or words as appropriate for their grade level? An example might be showing the student the set '7 1 6 7 2' on an index card for a few seconds (depending on grade level). The set is then removed. A few seconds later the student is asked to remember that set and find it out of the following choices:
Does the student have difficulty with these types of problems as appropriate for their grade level?
76. Does the student become confused at what to look at and/or distracted when there is a lot of written material on a page?
77. If the student looks at a drawing of a common object, shape, picture, letter, number, symbol, or word, is the student able to identify that item even if a small portion of it is not drawn, as appropriate for their grade level?
78. Does the student have difficulty comparing shapes visually? An example of this might be showing the student a picture of a completed shape. The student is then shown a picture of four or five puzzle pieces. The student is asked to choose the two or three puzzle pieces that make up the completed shape. Does the student have difficulty with these types of activities?
79. Does the student have difficulty relating their body to another object in the environment? Examples might be difficulty determining how far away another object is, how big it is compared to the student, the direction of the object's location compared to where the student is standing, and the position of that object compared to the student's position. Does the student have difficulty with these types of activities?
80. Does the student have difficulty identifying two similar designs, when one of the designs might be smaller, larger, upside-down, turned, or rotated?
81. Does the student get confused between left and right?
82. Does the student have difficulty telling if two words sound the same or different? The following pairs might be said to a student, for example:
Does the student have difficulty with these types of activities?
83. Is the student able to repeat a number sequence exactly as presented, as appropriate for their grade level? An example of this might be having the student face the wall so that they can't see your mouth. You might say to the student, '6...2...4...7'. The student would have to repeat those numbers in order. Could the student do this?
84. Is the student able to listen to a number sequence and reverse its order, as appropriate for their grade level? An example of this might be having the student face the wall so that they can't see your mouth. You might say to the student, '6...2...4'. Would the student be able to reverse the order (4...2...6)?
85. Does the student have difficulty listening to, and remembering, a list of words (not necessarily in order)? The number of words on the list would be appropriate for the student's grade level. Does the student have difficulty with this type of activity?
86. Does the student have difficulty repeating a sentence, after hearing that sentence? The length of the sentence would depend upon the student's grade level. Does the student have difficulty with this type of activity?
87. Does the student have difficulty understanding directions after hearing them? The complexity of the directions would depend upon the student's grade level. Does the student have difficulty with this type of activity?
88. Does the student have difficulty listening to a sequence of sounds and blending them together to make a word? For example, if the student heard:
the 'b' sound, (pause), the 'oo' sound, (pause), and the 't' sound Would the student have difficulty blending the sounds to figure out the word was 'boot'?
89. Does the student have difficulty understanding and focusing their attention on the person speaking, when there are background noises and talking?
90. When the student hears a sound, does the student have difficulty figuring out which direction the sound came from?
91. After hearing an appropriate question for the student's grade level, is the student most often able to think, reason, and answer that question? Even if incorrectly answered, the answer should follow a reasonable logic. Is the student able to answer questions logically?
92. When the student learns a new concept, do they have difficulty applying that concept to other situations?
93. If the student is having difficulty with English, is English the primary language spoken in the student's home? If the student is not having difficulty, click "not applicable".
94. Does the student have difficulty finding the words to express themself?
95. Is it difficult to understand the student when they are speaking, even though both you and the student are speaking the same language (this difficulty is based on a reason other than the student's dialect or regional accent)?
96. Does the student tend to mispronounce sounds and/or words?
97. Does the student tend to have difficulty repeating a given speech sound after hearing it?
98. Does the student tend to speak too quickly?
99. Does the student tend to speak too slowly?
100. When speaking, does the student tend to leave out sounds within words, or words within sentences?
101. When speaking, does the student tend to add sounds within words, or words within sentences?
102. When speaking, does the student tend to rearrange the sounds within a word incorrectly (mixing up the order of the sounds)?
103. When speaking, does the student tend to rearrange the words within a sentence incorrectly (mixing up the order of the words)?
104. Does the student tend to speak in incomplete sentences? An example of this might be where the student does not finish their sentences.
105. When speaking, does the student tend to use incorrect tenses or subject-verb agreements? Examples of incorrect usage might include: 'It snowed tomorrow. The boy run yesterday. They is going to the store.'
106. When speaking, does the student tend to use a limited vocabulary?
107. Does the student's behavior negatively affect their academic performance?
108. Does the student have difficulty forming positive relationships with their peers?
109. Does the student have difficulty forming positive relationships with adults/elders?
110. Does the student have difficulty working productively in a group?
111. Is the student motivated to do well?
112. Does the student have difficulty following rules?
113. Is the student most often aware of what they should do, without being told?
114. Is the student's behavior, most often, appropriate for common situations?
115. Does the student appear to be depressed?
116. Does the student appear to be overly active?
117. Does the student appear to be withdrawn?
118. Does the student tend to become easily frustrated?
119. Does the student tend to become excessively physical when angry?
120. Do you think the student tends to feel good about themself?
121. Is the student a danger to themself?
122. Is the student a danger to others?
123. Does the student tend to be "picked on" or bullied?
124. Is the student able to perform gross motor activities, appropriate for their grade level? Examples might include how the student performs during gym class, performance on the playground, sports performance, using "large" muscle groups to perform a physical activity, etc. Is the student able to perform these types of activities at or above their age/grade level?
125. Is the student able to perform fine motor activities, appropriate for their grade level? Examples might include using scissors, writing, sewing, typing, stringing beads, using "small" muscle groups, etc. Is the student able to perform these types of activities at or above their age/grade level?
