Diagnostic Pre-Assessment Form

Step 1 of 22 - General Information

General Information

Name:

Pronouns:

(e.g. he/him, they/them)

DOB:

DD slash MM slash YYYY

Age

Telephone Number

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

What is your first language?

What language do you speak at home with your family?

Do you speak any other languages?

If English is your second language, how long have you been speaking/learning English?

What is your job title or course title?

What is the reason you've requested the diagnostic assessment?

Is this assessment to help with your studies?

Yes

Please say what course you are studying, and when you are due to finish.

Please give brief details about any other college/educational experiences since leaving school.

Is this assessment to help with your work?

Yes

If so, please tell me your job title and give a brief description of your duties.

Can you tell me about the things you are good at? What do you consider to be your strengths?

Background Information

Have you had a diagnostic assessment before?

Yes

If so, when?

Do you have a report?

Yes

Development

Please tick yes if you experienced any of the following as a child

Ear infections, or grommets/glue ear

Yes

Vision problems e.g., squint, lazy eye/other

Yes

Speech or language difficulties

Yes

Speech therapy

Yes

If so, for how long and what age?

Late talker or had a stutter/stammer

Yes

Any difficulties with your birth, premature

Yes

Did you achieve your developmental milestones as expected

Yes

e.g., crawling, walking, talking?

Do you have any family members who have similar difficulties/have been identified with dyslexia or another specific learning difficulty?

Yes

Motor Co-ordination

Please tick yes if you had difficulties in any of the following areas as a child

Gross motor skills

Yes

e.g., riding a bike, learning to swim

Fine motor skills

Yes

e.g., fastening buttons or shoelaces

Hand/eye co-ordination

Yes

e.g., throwing/catching a ball

Would you call yourself clumsy?

Yes

Do you play any sports?

Yes

Education - School (Primary/Middle)

Did you have a problem learning to read?

Yes

Did you get any extra help?

Yes

e.g., one to one in class for reading/spelling

Did you have a settled primary education?

Yes

If not, how many different schools did you attend?

Did you attend regularly?

Yes

If not, could you tell me some of the reasons for not attending below?

Do you have any particular memories of primary school

e.g. teachers, experiences, coping with schoolwork?

School (Secondary)

Did school identify that you had a problem with learning?

Yes

Did you get any extra help?

Yes

If so, what sort of help?

Did you have a settled secondary education?

Yes

If not, how many different schools did you attend?

Did you attend school regularly?

Yes

If not, please say why

Do you have any particular memories of secondary school

e.g. teachers, experiences, coping with schoolwork?

What exams have you completed and the grades?

Did you have any exam access arrangements (reader, scribe, separate room etc)?

Reading

Please tick yes if you experience difficulties with any of the following currently. If you are not sure, please leave it blank.

Need to re-read frequently

Yes

Comprehension

Yes

Word recognition

Yes

Decoding

Yes

(i.e., if you come across an unfamiliar word can you break it down and sound it out?)

Reading out loud

Yes

Losing your place

Yes

Visual disturbance/discomfort

Yes

Have you ever used coloured overlays for reading?

Yes

If so, what colour?

Do you use any strategies to help with reading?

Writing & Spelling

Please tick yes if you experience difficulties with any of the following currently. If you are not sure, please leave it blank.

Remembering what words you want to use

Yes

Spelling

Yes

Grammar and/or punctuation

Yes

Sentence structure

Yes

Organisation and planning

Yes

Getting ideas down on paper

Yes

Proof reading

Yes

Do you use any strategies to help with writing?

Handwriting

Please tick yes if you experience difficulties with any of the following currently. If you are not sure, please leave it blank.

Copying

Yes

Letter reversals

Yes

(back to front or in the wrong order)

Difficult to read

Yes

Messy

Yes

(lots of crossings out)

Do you prefer to type rather than write by hand?

Yes

What are your IT Skills like?

e.g. can you use Word, search on the internet

Mathematics

Please tick yes if you experience difficulties with any of the following currently. If you are not sure, please leave it blank.

General proficiency

Yes

Memorising times tables

Yes

Memorising number facts

Yes

e.g., 8 + 2 = 10, or formulas

Long division or algebra

Yes

Using a calculator

Yes

Do you use any strategies to help with any difficulties?

Memory

Do you have any problems remembering things from a long time ago?

Yes

Do you have any problems remembering things that have just happened?

Yes

Do you have any problems remembering appointments and dates

Yes

What do you do to help you remember?

What is your concentration like?

Did your family or teachers have any concerns about your behaviour or ability to concentrate when you were younger?

Sequencing

Do you know the alphabet?

Yes

Can you recall the sequence of months, days or seasons?

Yes

Do you get confused with the order or letters in a word or phone numbers?

Yes

Language/listening behaviour

Please tick yes if you experience difficulties with any of the following currently. If you are not sure, please leave it blank.

Listening – in class, discussions, or conversations

Yes

Concentrating with background noise

Yes

Pronunciation

Yes

e.g., with multisyllabic words

Remembering the words you want to use

Yes

Listening & taking notes at the same time

Yes

Do you use any strategies to help with any difficulties?

Organisation

Do you struggle to organise your files or workload?

Yes

Do you struggle to organise your ideas, for example in written work?

Yes

Do you struggle to organise your time?

Yes

Do you struggle to organise yourself e.g. getting ready on time?

Yes

Spatial Temporal

Did have problems with learning to tell the time?

Yes

Can you tell the time now?

Yes

Do you have difficulties with awareness of time e.g. do you lose track of time, are you late for things?

Yes

Are you left-handed?

Yes

Do you get confused between left and right?

Yes

Do you get lost easily?

Yes

Can you read a map?

Yes

Could you follow a set of verbal directions?

Yes

Any problems with your balance?

Yes

Do you use any strategies to help with any difficulties?

Vision and Hearing

Do you have any problems with your hearing?

Yes

If so, please provide details:

Date of last hearing test

DD slash MM slash YYYY

Do you have any problems with your eyesight?

Yes

If so, please provide details:

Have you been prescribed and advised to wear any optical prescription lenses (i.e. glasses or contact lenses)?

Yes

Are these required for distance vision (e.g. television), near vision (e.g. reading), or both?

Do you wear your glasses / contact lenses as advised?

Yes

Do you have the prescribed glasses/contact lenses with you today?

Prescribed glasses/contact lenses should be worn for a SpLD assessment, unless intended for distance use only.

How long ago was your last sight-test or eye test by an optometrist (optician)?

Less than two years ago

More than two years ago

Never

Have you ever used coloured overlays or precision-tinted lenses?

Yes

Who recommended and provided these?

Why were they recommended?

Did they help?

Yes

If YES, in what way?

Do you still use them?

Yes

If not, why not?

Have you ever had hospital treatment for a problem with your eyes or vision?

Yes

For example... -wearing a patch for a ‘lazy eye’ (amblyopia)? -wearing glasses or having exercises to help correct a ‘turn’ in your eye (squint)? - any other condition?

Approximately how many hours per working/study day do you spend at a screen (phone, tablet, computer) etc?

Approximately how many additional hours per working /study day do you spend reading books, newspapers, comics or other paper-based texts?

Has your screen/reading/near work time increased recently?

Yes

If so, by how much?

Visual History Questionnaire*

*N.B. Please note the emphasis on the word often in questions 1-9, which is deliberately intended to identify when a symptom occurs frequently. Therefore, please answer NO if reported symptoms would be considered infrequent (e.g. rarely, occasionally, sometimes, <2-3 times per month).

Do you often get headaches when you read or study?

Yes

Do your eyes often feel sore, or gritty, or watery?

Yes

Does reading from white paper or from a bright screen often feel uncomfortable?

Yes

Does print often appear blurred, or go in and out of focus, when you are reading?

Yes

Does the print, or book, or screen, often appear double when you are reading?

Yes

Do words often seem to move or merge together when you are reading?

Yes

Do objects in the distance often appear more blurred after you have been reading?

Yes

Do you often have to screw up your eyes to see more clearly when you are reading?

Yes

Do you often move your eyes around or blink to make things clearer or more comfortable when you are reading?

Yes

Do you experience any other problems with your vision that interfere with your ability to read or study?

Yes

If yes, then please describe:

Consent

I consent to you collecting and processing my personal data (which includes special category personal data) in accordance with our privacy policy.(Required)

I consent

I do not consent (Please note, if you do not provide your consent for this then we will not be able to proceed with your diagnostic assessment).

Please read our privacy policy

Please confirm that you have read and agreed to the terms and conditions(Required)

I consent

I do not consent (Please note, if you do not provide your consent for this then we will not be able to proceed with your assessment).

Please read our Terms & Conditions

Has the assessment been paid by an external third party(Required)

Yes

(e.g. employer/parent/guardian/other)

Please indicate your explicit consent that you are happy for us to send a copy of your report and discuss the findings of your report with the paying third party. (Please note, if you do not provide your consent for this then we may not be able to proceed with your assessment. This will need to be discussed with the paying third party. Please save your pre-assessment form, and contact [email protected] to decide how to proceed).(Required)

I consent

I understand that if I wish to cancel, postpone or re-arrange within 5 working days of the appointment there will be a cancellation fee of £100 due. If I fail to attend or re-arrange on 3 occasions then up to the full fee may be charged.(Required)

Yes

I consent to Aim Forward contacting me about their services and further ways to support me in the future.(Required)

I consent

I do not consent

Signature

Name

Signature

Date

DD slash MM slash YYYY

Untitled

Diagnostic Pre-Assessment Form

General Information

Background Information

Development

Motor Co-ordination

Education - School (Primary/Middle)

School (Secondary)

Reading

Writing & Spelling

Handwriting

Mathematics

Memory

Sequencing

Language/listening behaviour

Organisation

Spatial Temporal

Vision and Hearing

Consent

Signature

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