AccessAbility
Dyslexia Screening Questionnaire
Name
Student no
Address
Telephone
E-mail
Date of birth
Course
Year of study
Tutor
Please return the completed form to:
AccessAbility
University of Exeter Forum
Stocker Road
Exeter EX4 4SZ
Or E-mail to AccessAbility@exeter.ac.uk
Once we receive this form we will contact you to book an appointment to discuss what to
do next.
Dyslexia Screening Questionnaire
1
AccessAbility
Have you been screened or tested before?
Yes/No
If yes, what were the results?
Background health history
Please tick which of the following you have experienced:
Ear infections
Speech/language difficulties
Vision problems
Allergies/asthma
Clumsy/co-ordination problems
Missed developmental milestones
Do any of your family experience similar problems, or have they been diagnosed with specific
learning difficulties (dyslexia, etc)?
Other comments on health:
Primary school
Please tick if any of the following are relevant to your experience of primary school:
Problems learning to read
Received extra help
Second language interference
Disruptions/missed school
Problems/delays in learning to tell the time, tie shoelaces, catch a ball, ride a bike:
Other comments on primary school experience:
Dyslexia Screening Questionnaire
2
AccessAbility
Secondary school/sixth form
Please tick if any of the following are relevant to your experience of secondary school:
Problems recognised by school
Received extra help
Received extra time in exams
Disruptions/missed school
Attitude of teachers/their comments:
Other comments on secondary school experience:
Please tell us about your educational experiences since leaving school:
What are your educational aims?
Self-assessment of difficulties:
Dyslexia Screening Questionnaire
3
AccessAbility
Language/listening
Please tick if you experience any of the following:
Trouble listening
Trouble concentrating with background
noise
Word retrieval problems
Problems listening and taking notes at the
same time
Pronunciation difficulties
Comments:
Reading
Please tick if you experience any of the following:
Need to re-read frequently
Difficulties reading out loud
Comprehension difficulties
Word recognition difficulties
Print ‘dances’, blurs or irritates eyes
Difficulties with breaking words down to
read them
Comments:
Spatial/temporal
Please tick if you experience any of the following:
Map reading difficulties
Left/right confusion
Get lost easily
Difficulties following verbal instructions
Comments:
Dyslexia Screening Questionnaire
4
AccessAbility
Writing and spelling
Please tick if you experience any of the following:
Difficulties getting ideas down on paper
Word finding difficulties
Problems with grammar/sentence
structure
Problems planning and organising work
Difficulties remembering what words look
like
Difficulties telling the difference between
sounds
Comments:
Maths
Please tick if you experience any of the following:
Difficulties memorising tables
Difficulties with long division
Difficulties remembering basic number
facts
General maths difficulties
Can’t use bus/train timetables
Comments:
Memory difficulties
Please tick if you experience any of the following:
Problems remembering the alphabet
Erratic memory
Problems with months/days/seasons
Difficulties remembering names/dates/facts
Forget telephone numbers
Other
Comments:
Dyslexia Screening Questionnaire
5
AccessAbility
Visual motor
Please tick if you experience any of the following:
Copying difficulties
Difficulties controlling pen
Letter reversals
Irregular/awkward letter construction
Unusual paper position
Problems with writing what’s intended
Unusual pen grip
Hand gets tired after short period of writing
Left handed
Other
Comments:
Dyslexia Screening Questionnaire
6