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First Name: |
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Last Name: |
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Grade (if in school): |
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Age of student: |
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Sex of student: |
MaleFemale |
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State in which you live: |
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Hand used for writing/drawing: |
RightLeftBoth |
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Primary Ethnic Origin: |
WhiteBlackHispanic/LatinoAsianAm IndianMixed |
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Is any medication taken on a regular
basis? If so, for what? |
NoADD/ADHDAllergyGrowthEmotion/Behavior |
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Has this student ever received any of these
Special Education Services? |
NoLDEBDSpeech/LangOHI |
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Are there other family members with
learning difficulties? |
NoParentSiblingAunt/UncleGrandparent |
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Were there any complications before or
during birth? |
YesNo? |
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Has there ever been a serious head
injury? |
YesNo? |
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Has there ever been any medical issue that
may have affected the brain? |
YesNo? |
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Did this student have many ear infections
during infancy or childhood? |
YesNo? |
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Is there an identified or suspected
attention deficit disorder (ADD or ADHD)? |
YesNo? |
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Does this student have an identified or
suspected Learning Disability? |
YesNo? |
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In your opinion, are there any behavior
problems which may interfere in school? |
YesNo? |
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Is there a visual problem that is not
fully correctable with glasses? |
YesNo? |
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Is there any hearing problem that is not
fully corrected? |
YesNo? |
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Has this person been absent from school more than most other students? |
YesNo? |
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Is this person fluent in the English language? |
YesNo? |
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What is the primary language spoken in the home? |
EnglishOther |
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How many years of education in English has this person received? |
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For the following 50
items please select the rating that best describes this student based on the scale to the right.
Please complete all items for an accurate rating, then click the "Submit Rating" button at the bottom of the page. |
1
Obvious Difficulty
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2
Apparent Weakness
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3
Average or Uncertain
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4
Not a Problem
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5
Obvious Strength
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1 |
Ability to understand or remember questions, directions, or verbal instructions. Like when a teacher is just lecturing without any charts or pictures. |
12345 |
2 |
Ability to quickly think through a difficult problem or situation. Does a better answer come later in the day or even the next day? |
12345 |
3 |
Ability to remember new phone numbers and/or addresses. |
12345 |
4 |
Ability to remember or understand the basic idea of what happened in a movie or story - general information rather than specific details. |
12345 |
5 |
Ability to remember the names of characters or other specific details in a story or movie. |
12345 |
6 |
Ability to get or stay organized. Does organization come easily? |
12345 |
7 |
Ability to pay attention to instruction, activities or games. |
12345 |
8 |
Ability to remember or follow complex directions or requests (involving 3 or more steps). Does the request need to be repeated? |
12345 |
9 |
Ability to read quickly and fluently.
For ages 4-7, ability to remember nursery rhymes. |
12345 |
10 |
Ability to quickly sound out new words.
For ages 4-7, ability to quickly identify numbers and letters. |
12345 |
11 |
Ability to understand what is read just using the "context" (without pictures).
For ages 4-7, ability to understand what is read to him/her (without looking at pictures). |
12345 |
12 |
Ability to understand what is read when there are pictures for clues. |
12345 |
13 |
Handwriting neatness.
For ages 4-7, ability to color neatly and stay within the lines. |
12345 |
14 |
Writing mechanics (spelling, punctuation, capitalization, etc.).
For ages 4-7, ability to play visual "memory" games. |
12345 |
15 |
Writing content. Ability to express ideas in writing when the "mechanics" don't matter.
For ages 4-7, ability to find the hidden pictures in "hidden picture" puzzles. |
12345 |
16 |
Letter/word orientation. This is a "difficulty" if letters are ever reversed (b/d, etc.), out of order in words or starting words with the wrong letter.
For ages 4-7, this is a difficulty if letters are often reversed. |
12345 |
17 |
Ability to remember specific formulas for solving math problems.
For ages 4-7, ability to remember basic addition and subtraction facts. |
12345 |
18 |
Ability to estimate or figure out the answer to math problems without using a specific formula. |
12345 |
19 |
Verbal speed - ability to talk quickly and clearly. |
12345 |
20 |
Verbal fluency without noticeable pauses or groping for words. Is it difficult to come up with the right words to express a thought? |
12345 |
21 |
Ability to solve visual, mechanical, or "hands on" puzzles or problems. |
12345 |
22 |
Ability to recognize voices (like on the telephone). |
12345 |
23 |
Ability to stay focused and recheck tasks without making careless mistakes. |
12345 |
24 |
Ability to be creative and come up with new ideas or new ways of doing something. |
12345 |
25 |
General sense of humor. Do you (does he/she) see humor in lots of situations or have difficulty understanding what others think is funny? |
12345 |
26 |
Rhythmic or musical skills (even if an instrument is not played). |
12345 |
27 |
Ability to "plan" and to break large tasks into smaller parts or steps. |
12345 |
28 |
Arts and crafts skills (drawing, painting, sculpture, etc.). |
12345 |
29 |
Ability to visualize and imagine things in his/her head (pictures, faces, words, numbers, etc.)? |
12345 |
30 |
Ability to accomplish long-term goals or projects. |
12345 |
31 |
Directional skills (right/left, north/south, etc.). |
12345 |
32 |
Ability to complete jigsaw puzzles. |
12345 |
33 |
Ability to remember the words of new popular songs? |
12345 |
34 |
Ability to remember the tunes to new popular songs? |
12345 |
35 |
Ability to cope with an unexpected change in plans. |
12345 |
36 |
Ability to cope with transitions from one activity to another. |
12345 |
37 |
Ability to remember the rules to games. |
12345 |
38 |
Ability to keep up with activities. Are you (is he/she) the first to start and/or finish something (4 or 5) or are others kept waiting (1 or 2)? |
12345 |
39 |
Ability to sit still for long periods of time? |
12345 |
40 |
Ability to control emotions and avoid overreacting to situations. |
12345 |
41 |
Ability to cope with disappointment. |
12345 |
42 |
Ability to begin tasks without being told or reminded. |
12345 |
43 |
Ability to keep busy to avoid being bored. |
12345 |
44 |
Ability to stick with or follow a schedule for homework or chores. |
12345 |
45 |
Awareness of homework assignments (does he/she come home knowing what to do?). |
12345 |
46 |
Ability to find or gather necessary materials to complete chores or assignments. |
12345 |
47 |
Ability to keep room or desk clean and organized. |
12345 |
48 |
Awareness of how his/her behavior affects others. |
12345 |
49 |
Sensitivity to the feelings of others. |
12345 |
50 |
Ability to stick with a difficult or unpleasant task. |
12345 |
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Participation Code (if you have one): |
If you don't know what this is, leave it blank |
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Click the "Submit Rating" button only once then wait several seconds to be taken to the confirmation page |
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