SpLD Screening Questionnaire Primary page content Personal details * Your name * Student number This can be found on your Goldsmiths ID card starting with 33. * Your gold.ac.uk email address Year of study Before we get started, please tell us why are you completing this screening? E.g. have you been asked to by a tutor, has a friend encouraged you, do you think you might have a dyslexia / dyspraxia or ADHD? Personal background * Have you been ever been diagnosed with a Specific Learning Difficulty (e.g. dyspraxia)? Yes No * Have you been ever been diagnosed with ADD or ADHD? Yes No * Do you have any mental health problems? Yes No * Do you have any vision or hearing problems? Yes No Please state if you had glue ear / grommets as child * Do you have any health conditions or have you been in an accident? Yes No * Are you currently taking any medication? Yes No * As a child, were you late in learning to talk? Yes No * Have you had any speech therapy? Yes No * As a child, did you have a lot of minor injuries? Yes No * Has anyone in your family been diagnosed with dyslexia, dyspraxia, ADHD or Autism? Yes No When did you last have an eye test? Enter the year of your last eye test * Have you ever used coloured overlays/tinted glasses? Yes No Language * Is English your first language? Yes No ...if no, what is your first language? In which language were you educated? School education At school, did you experience difficulties with any of the following: * Learning to read? Yes No * Learning to spell? Yes No * Structuring your ideas in writing? Yes No * Handwriting? Yes No * Reading aloud? Yes No * Mental arithmetic? Yes No * Concentration? Yes No * Did you miss long periods of school? Yes No * Did you get any extra support at school? For example have extra sessions with a TA or have private tuition? Yes No * Did you regularly run out of time in written examinations? Yes No * Did you receive any special exams arrangements (additional time, scribe, reader, etc.)? Yes No Motor co-ordination and spatial awareness * Do you confuse left and right? Yes No * Do you find map reading difficult? Yes No * Do you often get lost in unfamiliar places? Yes No * Do you find it hard to remember directions if they are given verbally? Yes No * Do you drive? Yes No If yes how many tests did you take to pass? * Can you ride a bike? Yes No If yes did it take a long time to learn? * At school did you enjoy team sports e.g. football or netball? Yes No * Do you often bump into things or people? Yes No * Do you often spill food and drink? Yes No * Do you find practical tasks (such as DIY) difficult? Yes No Reading * Do you read for pleasure? Yes No * Are you a slow reader compared to other students? Yes No * Do you dislike reading long books? Yes No * Do you dislike reading aloud? Yes No * Do you often forget what you have just read? Yes No * Do you re-read paragraphs to understand and absorb the meaning? Think about this in the context of academic texts rather than a novel / newspaper. Yes No * Do you find it hard to pick out relevant information (e.g. do you find it hard to know what to highlight or note down)? Yes No * Do you sometimes misread words? e.g. January / journey or hysterical / historical? Yes No * When you have a choice, do you tend to avoid activities that involve a lot of concentrated reading? Yes No * Are you able to spot mistakes when proofreading your own work? Yes No * Do you tend to move your lips and speak words quietly to yourself when you are reading? Yes No * When you are reading, do you often lose your place on the page? Yes No * Do the words sometimes blur or move? Yes No * Do you find it difficult to pronounce unfamiliar words? Yes No Writing * Do you make spelling mistakes (if no access to spellcheck)? Yes No * Do you sometimes confuse homophones (e.g. their/there/they’re)? Yes No * Is your handwriting difficult to read? Yes No * Do you have problems with sentence structure? Yes No * Do you have problems with grammar or punctuation? Yes No * Do you have problems structuring essays? Yes No * Do you have problems writing meaningful notes in lectures? Yes No Memory and concentration * Do you think you have a poor short term memory? Yes No * Do you often forget names? Yes No * Do you have to write things down so as not to forget them? Yes No * Do you often lose things or forget where you have put them? E.g. keys / phone etc. Yes No * Do you find it difficult to remember facts for examinations? Yes No * Do you run out of time in written timed examinations? Yes No * Are you easily distracted? Yes No * Do you lose track of conversations? Yes No * Do you interrupt people? Yes No * Do you ‘zone out’ or day dream in lectures? Yes No * Do you fidget / find it hard to keep still? Yes No Time management and organisation * Do you procrastinate and put off starting a piece of work? Yes No * Do you find it hard to meet coursework deadlines? Yes No * Do you find it hard to keep your work organised? Yes No * Are you generally disorganised and untidy? Yes No * Are you often late for appointments? Yes No Numbers and maths * Do you find it difficult to do sums in your head? Yes No * Did you find it hard to learn your multiplication tables? Yes No * Do you often confuse or mix up certain numbers? Yes No * Do you find formulas confusing or difficult to learn? Yes No Leave blank Keep this field empty Data protection and confidentiality We will store and use the information you send in order to provide our service to you. We will only contact you in relation to this enquiry. Read our Privacy Notices to understand how we will use what you send us.