Student Full Name
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Date of Birth
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Gender
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Please Select
Male
Female
Is Student a Native English Speaker
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Yes
No
Name of Person Completing Survey
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Relationship to Student
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Email Address
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Mobile Number
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How did you find out about us?
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Friend
School
Professional Recommendation
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Internet Forum/Discussion Group
Internet Listing
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Instructions: Read each of the following statements and rate the student by selecting the column that most closely matches him/her for each item. Please be sure to rate EVERY statement. Compared to normal behaviour for others of the same age and gender as the student, this student's behaviour occurs:
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Less Than
About The Same
Slightly More
Much More
Very Much More
1. Has difficulty maintaining attention
2. Makes spelling errors in written work
3. Has a poor sense of direction/map reading skills
4. Is impulsive
5. Often asks to have things repeated
6. Has difficulty planning steps to solve problems
7. Completes assignments slowly
8. Avoids prolonged mental effort
9. Has difficulty sounding out unknown words
10. Misreads similar words
11. Has difficulty comprehending written materials
12. Distracted from the task at hand
13. Thoughts and materials are poorly organised
14. Generally does things slowly
15. Oral reading is slow or choppy
16. Has poor study or work habits
17. Has difficulty creating mental pictures
18. Has problems remembering
19. Poor or slow at Maths
20. Has difficulty doing two things at once
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