Screening Survey 5 yrs. & Older

Please read each question and respond 'yes' for any item that describes your child.

Question Title

* 1. Please check the appropriate response below regarding your child's speech and language skills

	Yes	N/A
My child is unable to produce most speech sounds correctly	My child is unable to produce most speech sounds correctly Yes	My child is unable to produce most speech sounds correctly N/A
My child has difficulty following/understanding directions	My child has difficulty following/understanding directions Yes	My child has difficulty following/understanding directions N/A
My child has difficulty answering wh- questions, including hypothetical situations	My child has difficulty answering wh- questions, including hypothetical situations Yes	My child has difficulty answering wh- questions, including hypothetical situations N/A
My child uses a speech pattern, including stuttering, that causes embarrassment or frustration	My child uses a speech pattern, including stuttering, that causes embarrassment or frustration Yes	My child uses a speech pattern, including stuttering, that causes embarrassment or frustration N/A
My child has difficulty with conversational skills—initiating, turn taking	My child has difficulty with conversational skills—initiating, turn taking Yes	My child has difficulty with conversational skills—initiating, turn taking N/A
My child has difficulty with reading comprehension	My child has difficulty with reading comprehension Yes	My child has difficulty with reading comprehension N/A
My child often drools	My child often drools Yes	My child often drools N/A
My child has difficulty using appropriate pronouns (he/she) and verb tense (walk/walked)	My child has difficulty using appropriate pronouns (he/she) and verb tense (walk/walked) Yes	My child has difficulty using appropriate pronouns (he/she) and verb tense (walk/walked) N/A

Question Title

* 2. This section describes skills related to social emotional development, sensory processing, and other related behaviors. Please check the appropriate response for each item below.

	Yes	N/A
My child has difficulty playing with same aged peers or following rules of a game	My child has difficulty playing with same aged peers or following rules of a game Yes	My child has difficulty playing with same aged peers or following rules of a game N/A
My child is more active than other kids-- frequently moving, rocking, fidgeting, spinning	My child is more active than other kids-- frequently moving, rocking, fidgeting, spinning Yes	My child is more active than other kids-- frequently moving, rocking, fidgeting, spinning N/A
My child has extreme fears or anxiety that interfere with daily routine	My child has extreme fears or anxiety that interfere with daily routine Yes	My child has extreme fears or anxiety that interfere with daily routine N/A
My child has difficulty with transitions, changes in routine, or is easily frustrated	My child has difficulty with transitions, changes in routine, or is easily frustrated Yes	My child has difficulty with transitions, changes in routine, or is easily frustrated N/A
My child is a picky eater-- particular about food tastes/textures/brands	My child is a picky eater-- particular about food tastes/textures/brands Yes	My child is a picky eater-- particular about food tastes/textures/brands N/A
My child covers his ears in loud environments or seems to not hear when name is called	My child covers his ears in loud environments or seems to not hear when name is called Yes	My child covers his ears in loud environments or seems to not hear when name is called N/A
My child tends to be rough during play or unintentionally hurts others	My child tends to be rough during play or unintentionally hurts others Yes	My child tends to be rough during play or unintentionally hurts others N/A
My child avoids moving toys on playground or having feet off the ground	My child avoids moving toys on playground or having feet off the ground Yes	My child avoids moving toys on playground or having feet off the ground N/A
My child avoids getting hands messy	My child avoids getting hands messy Yes	My child avoids getting hands messy N/A
My child is bothered by certain clothing or often touches objects/people to the point of irritation	My child is bothered by certain clothing or often touches objects/people to the point of irritation Yes	My child is bothered by certain clothing or often touches objects/people to the point of irritation N/A
My child needs significant support to recover when upset	My child needs significant support to recover when upset Yes	My child needs significant support to recover when upset N/A
My child has frequent tantrums	My child has frequent tantrums Yes	My child has frequent tantrums N/A
My child has difficulty identifying left vs. right sides of the body	My child has difficulty identifying left vs. right sides of the body Yes	My child has difficulty identifying left vs. right sides of the body N/A

Question Title

* 3. This section describes skills related to a child's fine and gross motor development. Please check the appropriate response below.

	Yes	N/A
My child's writing is illegible, or child produces written work very slowly	My child's writing is illegible, or child produces written work very slowly Yes	My child's writing is illegible, or child produces written work very slowly N/A
My child has difficulty cutting out a circle or other simple shapes	My child has difficulty cutting out a circle or other simple shapes Yes	My child has difficulty cutting out a circle or other simple shapes N/A
My child has difficulty with buttons, snaps, zippers, or shoe tying	My child has difficulty with buttons, snaps, zippers, or shoe tying Yes	My child has difficulty with buttons, snaps, zippers, or shoe tying N/A
My child has difficulty getting dressed (socks, shoes, shirts, etc.)	My child has difficulty getting dressed (socks, shoes, shirts, etc.) Yes	My child has difficulty getting dressed (socks, shoes, shirts, etc.) N/A
My child needs physical assist or verbal cues for basic self-care tasks (wash hands, brush teeth, use fork/spoon)	My child needs physical assist or verbal cues for basic self-care tasks (wash hands, brush teeth, use fork/spoon) Yes	My child needs physical assist or verbal cues for basic self-care tasks (wash hands, brush teeth, use fork/spoon) N/A
My child appears clumsy, uncoordinated, (falling, tripping) or bumps into people/objects	My child appears clumsy, uncoordinated, (falling, tripping) or bumps into people/objects Yes	My child appears clumsy, uncoordinated, (falling, tripping) or bumps into people/objects N/A
My child has a slumped posture or tires easily when holding a particular position/posture	My child has a slumped posture or tires easily when holding a particular position/posture Yes	My child has a slumped posture or tires easily when holding a particular position/posture N/A
My child has difficulty catching, throwing, or kicking a ball	My child has difficulty catching, throwing, or kicking a ball Yes	My child has difficulty catching, throwing, or kicking a ball N/A
My child has difficulty with bike riding, pumping a swing	My child has difficulty with bike riding, pumping a swing Yes	My child has difficulty with bike riding, pumping a swing N/A

Question Title

* 4. This section describes skills related to visual development. Because vision impacts so many other skills, some of these questions may be similar to those found elsewhere in this checklist. Please check YES for all that apply

	Yes
Complains of blurred vision	Complains of blurred vision Yes
Rubs eyes frequently or squints	Rubs eyes frequently or squints Yes
Covers or closes one eye	Covers or closes one eye Yes
Occasionally sees double	Occasionally sees double Yes
Able to read for only a short time	Able to read for only a short time Yes
Poor reading comprehension	Poor reading comprehension Yes
Holds things very close or leans close to table when working	Holds things very close or leans close to table when working Yes
Reports eyes feel tired	Reports eyes feel tired Yes
Reports headaches during reading	Reports headaches during reading Yes
Moves head excessively when reading	Moves head excessively when reading Yes
Frequently loses place or skips lines when reading	Frequently loses place or skips lines when reading Yes
Uses finger to keep place while reading	Uses finger to keep place while reading Yes
Demonstrates short attention span	Demonstrates short attention span Yes

Question Title

* 5. Please check YES for all that apply

Screening Survey 5 yrs. & Older

Question Title

* 1. Please check the appropriate response below regarding your child's speech and language skills

Question Title

* 2. This section describes skills related to social emotional development, sensory processing, and other related behaviors. Please check the appropriate response for each item below.

Question Title

* 3. This section describes skills related to a child's fine and gross motor development. Please check the appropriate response below.

Question Title

* 4. This section describes skills related to visual development. Because vision impacts so many other skills, some of these questions may be similar to those found elsewhere in this checklist. Please check YES for all that apply

Question Title

* 5. Please check YES for all that apply

Question Title

* 6. Age of my child:

Question Title

* 7. Name and PHONE NUMBER OR EMAIL of person completing this form (note: you will only be contacted regarding the results of this survey):

Question Title

* 8. When is the best time to reach you to discuss the results of this checklist?

	Yes
Mixes up words with similar beginnings	Mixes up words with similar beginnings Yes
Difficulty recognizing letters, words, or simple shapes and forms	Difficulty recognizing letters, words, or simple shapes and forms Yes
Difficulty distinguishing the main idea from insignificant details	Difficulty distinguishing the main idea from insignificant details Yes
Difficulty learning basic math concepts of size, magnitude, and position	Difficulty learning basic math concepts of size, magnitude, and position Yes
Difficulty visualizing what is read	Difficulty visualizing what is read Yes
Poor speller	Poor speller Yes
Difficulty recalling visually presented material	Difficulty recalling visually presented material Yes
Sloppy handwriting and drawing, or can’t draw well	Sloppy handwriting and drawing, or can’t draw well Yes
Difficulty coloring inside the lines	Difficulty coloring inside the lines Yes
Poor copying skills	Poor copying skills Yes
Able to respond orally but not in writing	Able to respond orally but not in writing Yes
Trouble learning left and right	Trouble learning left and right Yes
Reverses letters and words	Reverses letters and words Yes
Difficulty writing and remembering letters and numbers	Difficulty writing and remembering letters and numbers Yes
Reads slowly	Reads slowly Yes
Reading comprehension worsens as reading continues	Reading comprehension worsens as reading continues Yes
Confuses similar words or doesn’t recognize the same word on a different line	Confuses similar words or doesn’t recognize the same word on a different line Yes
Takes a long time to copy from the board or makes mistakes	Takes a long time to copy from the board or makes mistakes Yes
Poor, unevenly spaced handwriting, writes up or downhill	Poor, unevenly spaced handwriting, writes up or downhill Yes
Omits words when readings, especially small ones	Omits words when readings, especially small ones Yes
Copies math problems and results incorrectly	Copies math problems and results incorrectly Yes
Omits numbers or can’t tell the difference between similar numbers	Omits numbers or can’t tell the difference between similar numbers Yes