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Dyslexia Questionnaire
If your thinking of coming for an appointment fill in the questionnaire below to save time on the day.
 Your Details:
  
Your Full Name:
Your Telephone No:
Your E-mail Address:
 
 Visual Skills:
  
Are you / Do you...
Unstable on their feet or trips excessively:
Tend to bump into doorways/table edges excessively:
Likely to misjudge/spill/knock things over excessively:
Confident on swings/slides/climbing frames:
Able to catch/throw/kick well:
Susceptible to car sickness:
 
Do you complain of words in books or on the blackboard:
Jumping:
Wobbling:
Fading:
Going Black or White:
Double or Blurred:
Other(Please state):
 
Do you...
Have Headaches:
If so, where?
When?
How often?
 
Have you noticed having...
Red eyes:  
Shadows under eyes:  
Watery eyes:  
One eye turning in or out:  
Closing/Covering one eye:  
Turning or tilting their head:  
Blinking/Squinting  
 
Do you...
Seem to scan but not understand what they have read:
Need to use a finger to follow the print:
Have difficulty colouring in:
Follow with head movements when reading:
Have difficulty copying from the board:
Lose his place on the page frequently:
Fail to recoginse known words:
Reads better from flash cards than in books:
Have poor letter formation:
Seem to write off the line:
Do any of the above become worse or obvious the longer the task takes:
 
 Learning and Communication Skills:
  
Do you...
Seem over sensitive to sound:
Misinterpret questions:
Get confused by similar sounding words:
Require repetition:
Have difficulty following sequential instructions:
Have cluttered speech:
Have hesitant speech:
Have difficulty with speech sounds:
Dislike performing in a group:
Appear to listen but not understand:
Have difficulty organising thoughts into sentances:
 
   
 
   
 
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 © 2004 Stephen Wilcox Optometry