This is the questionnaire for the 5 - 7 age range.
Please ensure all questions are answered correctly.
Only tick the appropriate box and don't leave any blank, at the end of the questionnaire press the "Hand it in" button for our hairy expert to have a look at and make his recommendations.

Did / does your child have:
 
Yes
No
Some
1. Early speech difficulties
2. Difficulty hearing sounds in words (e.g. th/f: b/p/d etc)
3. Glue ear or hearing problems in the past
4. Little sense of Right / Left
5. Poor fine motor control (e.g. when cutting, sticking, doing up buttons)
6. Mirror writing, or does he/she constantly alter the order of letters and numbers (e.g. 'hlep' for 'help' or 'from' for 'form' or '21' for '12' etc)
7. Difficulty in forming letters and numbers
8. Consistantly confuses b/d: p/b/d: i/j: n/u etc)
9. Difficulty in remembering instructions
10. Difficulty in remembering sequences (e.g. days of the week, their birthday, addresses etc)
11. Difficulty in tying shoe laces and buttons and with the order in which they get dressed.
12. Temper tantrums and signs of frustration for no apparent reason.
13. Day dream or 'switch off' at school and sometimes at home when faced with words, writing or reading tasks.
14. Difficulty in remembering key words and sounds taught at school, (words such as 'was', 'who'). He/she appears to learn them for a test but soon forgets them again.
15. Difficulty copying from a book or the board.
16. Reluctance to go to school after a happy start. Reluctance gets more defined as the work becomes harder.
17. Is he/she falling behind at school despite appearing bright in other ways.
18. Are any other members of the family dyslexic or experience similiar difficulties, or have had difficulty learning to read and write at school.
Thank you for taking the time to fill out the questionnaire, now 'Hand it in' to our expert by pressing the button and finding out what he thinks.


Bristol Dyslexia Centre, 10 Upper Belgrave Road, Clifton, Bristol, BS8 2XH.
Tel: 0117 9739405 Fax: 0117 9239703