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Screening Survey 5 yrs. & Older
Please read each question and respond 'yes' for any item that describes your child.
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
Yes
N/A
My child has difficulty following/understanding directions
Yes
N/A
My child has difficulty answering wh- questions, including hypothetical situations
Yes
N/A
My child uses a speech pattern, including stuttering, that causes embarrassment or frustration
Yes
N/A
My child has difficulty with conversational skills—initiating, turn taking
Yes
N/A
My child has difficulty with reading comprehension
Yes
N/A
My child often drools
Yes
N/A
My child has difficulty using appropriate pronouns (he/she) and verb tense (walk/walked)
Yes
N/A
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
Yes
N/A
My child is more active than other kids-- frequently moving, rocking, fidgeting, spinning
Yes
N/A
My child has extreme fears or anxiety that interfere with daily routine
Yes
N/A
My child has difficulty with transitions, changes in routine, or is easily frustrated
Yes
N/A
My child is a picky eater-- particular about food tastes/textures/brands
Yes
N/A
My child covers his ears in loud environments or seems to not hear when name is called
Yes
N/A
My child tends to be rough during play or unintentionally hurts others
Yes
N/A
My child avoids moving toys on playground or having feet off the ground
Yes
N/A
My child avoids getting hands messy
Yes
N/A
My child is bothered by certain clothing or often touches objects/people to the point of irritation
Yes
N/A
My child needs significant support to recover when upset
Yes
N/A
My child has frequent tantrums
Yes
N/A
My child has difficulty identifying left vs. right sides of the body
Yes
N/A
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
Yes
N/A
My child has difficulty cutting out a circle or other simple shapes
Yes
N/A
My child has difficulty with buttons, snaps, zippers, or shoe tying
Yes
N/A
My child has difficulty getting dressed (socks, shoes, shirts, etc.)
Yes
N/A
My child needs physical assist or verbal cues for basic self-care tasks (wash hands, brush teeth, use fork/spoon)
Yes
N/A
My child appears clumsy, uncoordinated, (falling, tripping) or bumps into people/objects
Yes
N/A
My child has a slumped posture or tires easily when holding a particular position/posture
Yes
N/A
My child has difficulty catching, throwing, or kicking a ball
Yes
N/A
My child has difficulty with bike riding, pumping a swing
Yes
N/A
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
Yes
Rubs eyes frequently or squints
Yes
Covers or closes one eye
Yes
Occasionally sees double
Yes
Able to read for only a short time
Yes
Poor reading comprehension
Yes
Holds things very close or leans close to table when working
Yes
Reports eyes feel tired
Yes
Reports headaches during reading
Yes
Moves head excessively when reading
Yes
Frequently loses place or skips lines when reading
Yes
Uses finger to keep place while reading
Yes
Demonstrates short attention span
Yes
5.
Please check YES for all that apply
Yes
Mixes up words with similar beginnings
Yes
Difficulty recognizing letters, words, or simple shapes and forms
Yes
Difficulty distinguishing the main idea from insignificant details
Yes
Difficulty learning basic math concepts of size, magnitude, and position
Yes
Difficulty visualizing what is read
Yes
Poor speller
Yes
Difficulty recalling visually presented material
Yes
Sloppy handwriting and drawing, or can’t draw well
Yes
Difficulty coloring inside the lines
Yes
Poor copying skills
Yes
Able to respond orally but not in writing
Yes
Trouble learning left and right
Yes
Reverses letters and words
Yes
Difficulty writing and remembering letters and numbers
Yes
Reads slowly
Yes
Reading comprehension worsens as reading continues
Yes
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
Yes
Poor, unevenly spaced handwriting, writes up or downhill
Yes
Omits words when readings, especially small ones
Yes
Copies math problems and results incorrectly
Yes
Omits numbers or can’t tell the difference between similar numbers
Yes
6.
Age of my child:
7.
Name and PHONE NUMBER OR EMAIL of person completing this form (note: you will only be contacted regarding the results of this survey):
8.
When is the best time to reach you to discuss the results of this checklist?