Name

City

Phone Number (Include area code)

E-mail

Male          Female

Adult          Child

Is there a family history of reading difficulties?

Yes       No

  Does the individual have or did he/she have any:

Early speech and/or language problems?

Yes       No

History of inner ear infections as a child?

Yes       No

Hearing difficulties?

Yes       No

Poor reading and/or spelling skills?

Yes       No

Poor math and/or number skills?

Yes       No

Poor listening skills?

Yes       No

Poor attention and/or concentration?

Yes       No

Known or suspected coordination difficulties?

Yes       No

Known or suspected visual difficulties?

Yes       No

Allergies?

Yes       No

Has the individual had their eyes tested recently?

Yes       No

Has the individual had their hearing tested recently?

Yes       No

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