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 ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- north allegheny school district
- wscc english home
- kulm public school district 7 po box g
- fy20 fund code 152 board package
- highlights from the 2005 improving literacy
- pre reading questionnaire north allegheny
- north reading public schools cap 2015
- welcome to the north shore district event nsde
- north east independent school district
Related searches
- gadsden independent school district anthony nm
- gadsden independent school district nm
- gadsden independent school district homepage
- gadsden independent school district ho
- gadsden independent school district home
- gadsden independent school district website
- east chicago school district indiana
- east china school district calendar
- east china school district mi
- east china school district sports
- east china school district superintendent
- east china school district administration