NORTH EAST INDEPENDENT SCHOOL DISTRICT



NORTH EAST INDEPENDENT SCHOOL DISTRICTParent Response Form – Dyslexia AssessmentStudent ___________________________________ Age _____ Date of Birth __________School ______________________________ Grade ____ Date ______________________Student’s address ____________________________ Zip __________ Phone _____________To aid in assessing the problems your child is experiencing in school and to detect the possibility of dyslexia, please answer each of the following questions. YESNOFAMILY HISTORY ________1. Have any other members of the family had learning problems?If yes, what relative?_______________________________________What type of learning difficulty? ______________________________PHYSICAL HISTORY________2a. Has your child ever been critically or chronically ill?Explain: _________________________________________________________2b. Has your child had any of the following: (Please circle)extremely high fever - severe blow to the head – chronic ear infections - allergies Other physical problems which may cause difficultylearning: Explain:__________________________________________________3. Does your child seem to have trouble hearing? Seeing?(Please circle) If yes, explain:____________________________________________________4. Is your child currently taking medication regularly? If yes, please list medication and condition for which it is being taken:________________________________________________________BEHAVIOR OBSERVATIONS________5. Do you often have to repeat instructions to your child?________6. Does your child seem to have difficulty following directions?________7. Does your child spend more time on homework than seems appropriatefor his/her age and grade?________8. Does your child need an extraordinary amount of help with homework?________9. Does your child have more difficulty in reading, writing, and spelling than in other subjects?________10. Do you spend time reading to your child?________11. Does your child read to you?________12. Does your child seem to enjoy school?________13. Does your child have difficulty staying focused on his/her work?________14. Is your child easily distracted while reading or doing homework?On the back of this page, please add any other information such as recent changes in the family or health that you feel may be helpful.____________________________________________________________________Parent/Guardian SignaturePrinted Name of Parent/Guardian ................
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