AccessAbility

Dyslexia Screening Questionnaire

Name
Student no
Address
Telephone / E-mail
Date of birth
Course / Year of study
Tutor

Please return the completed form to:

AccessAbility
University of Exeter Forum
Stocker Road
Exeter EX4 4SZ

Or E-mail to

Once we receive this form we will contact you to book an appointment to discuss what to do next.

Have you been screened or tested before? / Yes/No
If yes, what were the results?
Background health history
Please tick which of the following you have experienced:
Ear infections / Speech/language difficulties
Vision problems / Allergies/asthma
Clumsy/co-ordination problems / Missed developmental milestones
Do any of your family experience similar problems, or have they been diagnosed with specific learning difficulties (dyslexia, etc)?
Other comments on health:
Primary school
Please tick if any of the following are relevant to your experience of primary school:
Problems learning to read / Received extra help
Second language interference / Disruptions/missed school
Problems/delays in learning to tell the time, tie shoelaces, catch a ball, ride a bike:
Other comments on primary school experience:
Secondary school/sixth form
Please tick if any of the following are relevant to your experience of secondary school:
Problems recognised by school / Received extra help
Received extra time in exams / Disruptions/missed school
Attitude of teachers/their comments:
Other comments on secondary school experience:
Please tell us about your educational experiences since leaving school:
What are your educational aims?
Self-assessment of difficulties:
Language/listening
Please tick if you experience any of the following:
Trouble listening / Trouble concentrating with background noise
Word retrieval problems / Problems listening and taking notes at the same time
Pronunciation difficulties
Comments:
Reading
Please tick if you experience any of the following:
Need to re-read frequently / Difficulties reading out loud
Comprehension difficulties / Word recognition difficulties
Print ‘dances’, blurs or irritates eyes / Difficulties with breaking words down to read them
Comments:
Spatial/temporal
Please tick if you experience any of the following:
Map reading difficulties / Left/right confusion
Get lost easily / Difficulties following verbal instructions
Comments:
Writing and spelling
Please tick if you experience any of the following:
Difficulties getting ideas down on paper / Word finding difficulties
Problems with grammar/sentence structure / Problems planning and organising work
Difficulties remembering what words look like / Difficulties telling the difference between sounds
Comments:
Maths
Please tick if you experience any of the following:
Difficulties memorising tables / Difficulties with long division
Difficulties remembering basic number facts / General maths difficulties
Can’t use bus/train timetables
Comments:
Memory difficulties
Please tick if you experience any of the following:
Problems remembering the alphabet / Erratic memory
Problems with months/days/seasons / Difficulties remembering names/dates/facts
Forget telephone numbers / Other
Comments:
Visual motor
Please tick if you experience any of the following:
Copying difficulties / Difficulties controlling pen
Letter reversals / Irregular/awkward letter construction
Unusual paper position / Problems with writing what’s intended
Unusual pen grip / Hand gets tired after short period of writing
Left handed / Other
Comments:

Dyslexia Screening Questionnaire 1