Schools Questionnaire

Could you please complete the questions below to aid our analysis of this child’s needs in the Multi-Sensory Training Centre. Thank you for your cooperation.

If possible we would like as up to date an assessment of the child’s level of school performance for when we first see them in clinic. We would like if possible to have an age equivalent for key areas such as reading, spelling, writing age and ability. We would also like to ask if you would at a future date give us an assessment via a questionnaire of their level in key areas at that time. This is so we can monitor the success of the program we have in place and work on areas to improve it.

Please indicate if this is agreeable to you
This data will then be collated and used for statistical analysis.
Child's Name:
DOB:

School Performance:

Has an educational psychologist assessed this child for specific learning problems?
If yes, please state when and what diagnosis was given: / /

Learning difficulties: Please indicate if the child is having difficulties in the following areas.

Reading
Spelling
Writing
Maths

Other, please specify:

Reading

We would be very grateful if an up-to-date reading age were available.

Child's reading age if known: Years Months
Test used and date given:
Your own impression of their reading attainment, given their intellectual ability

Spelling


Do you feel their spelling is
Spelling age if known: Years Months
Test used and date given:

Does the child spell phonetically?

Any comments you would like to make about their spelling:

Writing


What is the child's writing ability in approximate age? Years Months
Do they have difficulty in forming letters or words when copying?
Are there any problems with pen grip?
Does their writing deteriorate rapidy?
Do they complain of discomfort when writing?
Is their writing neat?
Does their handwriting slope up or down or get bigger across the page?
Do they reverse letters or words?
Is the problem with writing, due to spelling difficulties?
Do they find it hard to communicate ideas on paper?

Any comments you would like to add:

Concentration

Do they have problems with concentration?
If yes, please give brief details here:

Memory

Do they have any problems with long-term memory?
Are there problems with short-term memory?

Do you feel short-term memory is worse for visual or auditory memory?
Please specify:
Are their memory problems related to seqential processing of auditory and/or visual information? Please specify here:
Do they have problems remembering a series of instructions?
Are they good at organising what they have to do?
Do they usually finish their work on time?
Are they good at drawing?
Are they good at making 3D models?

Please write any additional information you may feel may be relevant:

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