Ages 5-7 Your answers to these seven questions can indicate if your child has potential learning challenges.

1. Is your child having difficulty recognizing letters or numbers?

   Y/N

2. Is your child having difficulty holding his pencil with his thumb and index finger?

   Y/N

3. Is your child having difficulty following a two-step direction?

   Y/N

4. Is your child having difficulty answering before and after questions?

   Y/N

5. Is your child having difficulty pronouncing some sounds or words?

   Y/N

6. Is your child having difficulty copying simple geometric figures with accuracy?

   Y/N

7. Is your child having difficulty understanding left and right?

   Y/N

Ages 8 and Up -Your answers to these ten questions can indicate if your child has potential learning challenges.

1. Does your child struggle with reading quickly and understanding what he/she has read?

   Y/N

2. Does your child forget math facts?

   Y/N

3. Does your child get frustrated and spend an unreasonable amount of time on homework?

   Y/N

4. Is your child unaware of time?

   Y/N

5. Does your child have difficulty organizing personal space and time?

   Y/N

6. Does your child have difficulty focusing?

   Y/N

7. Does your child have difficulty following three-step directions?

   Y/N

8. Does your child have difficulty writing legibly?

   Y/N

9. Does your child have difficulty spelling?

   Y/N

10. Does your child have difficulty solving problems?

    Y/N

Questionnaire