ADULT’S QUESTIONNAIRE

Proposed date for assessment

 

Full Name

 

Date of Birth and Age (yy/mm)

 

Home Address & Post Code

 

Phone Nos day and evening

 

email address

 

Occupation

 

STUDENT DETAILS (you may need to ask your parents for information on these questions!)

Do you agree to a copy of your details and progress being kept on our computer to be used solely for our internal administrative purposes? Note - This is essential for the assessment and to comply with the Data Protection Act.

 

Do you agree to your photograph being taken to incorporate into the report and kept on our computer, again to be used solely for our internal administrative purposes? Note - This is essential to produce a graphical report and to comply with the Data Protection Act.

 

Did you crawl, what age were you and for how long?

 

Are you well coordinated or sometimes a bit clumsy?

 

At what age did you:

  • talk? (or early, normal, late)
  • walk? (or early, normal, late)

 

Hearing

  • as a child, did you have any:

1.       ear problems? e.g. glue ear or grommets

2.       hearing problems?

  • did you have any current hearing problems?
  • when did you last have a hearing test?

 

Sight

  • as a child, did you have any visual problems?
  • do you currently have any visual problems?
  • when did you have your last eyesight test?
  • Do you have any indication of colour-blindness?

 

Were there any pre-natal/natal/post natal difficulties? (e.g. delayed breathing, lack of oxygen)

Please give details

Were you absent from school for any significant length(s) of time?

Please give details

As a child, did you suffer any family or personal trauma that may have contributed to learning difficulties?

Please give details

At school, did you receive any or all of the following

a.    conventional teaching of reading and spelling?

b.    adequate teaching of reading and spelling?

c.    additional tuition for reading and spelling?

Please give details

Is there any history of learning difficulties within your family, especially any of your brothers, father or grand-father? What is the occupation of your father?

Please give details

What concerns you most about your learning. (Enjoyment of reading, spelling performance, maths, self esteem, ridicule, self worth etc.)

Please give details.

How did you find out about us?

Please give details

Signature

Date