Confidential Pre-Screening Questionnaire

CONFIDENTIAL PRE-SCREENING QUESTIONNAIRE

1. PERSONAL INFORMATION

Name: Jane

Date of Birth: DD/MM/YY

College: X College

Course: Natural Sciences

Year: year X (undergraduate)

Email: [email protected]

2. BACKGROUND

What are the main difficulties you currently experience? I read very slowly when I read to myself – I have to hear a voice in my head read the words individual before any information sinks in. I cannot skim read at all. If I tried I would not absorb any information. Also I am not good at reading out-loud. I will either read the words out individually or try to read fluidly and accidentally read the phrases wrongly. I am bad a reading words that I’ve never seen written down before. I often have difficulty articulating thoughts verbally too. In an interview, for example, I struggle to explain thought processes coherently and I can’t think about two things at once, often leading to me having a thought but losing it after having to explain something else. Writing – I can explain myself more clearly through writing because I have to time to process information that I couldn’t do quickly enough in speech. When typing I constantly delete and edit things I’ve written – something I wish I could do when hand-writing! My spelling and grammar is worse than some people but not disastrous. I sometimes miss out words – often the second word of a sentence e.g. “I to go” instead of “I have to go”. Recently I also keep mixing up the word “dominate” and “nominate”.

Is there any history of dyslexia, motor co-ordination or AD(H)D in your family (including parents, grandparent, siblings or cousins)? YES Details: My younger brother (19 yrs old) is diagnosed with dyslexia. My Dad will also claim that he suffers too but is not diagnosed.

Have you had any test in the past for a specific learning difficulty (such as dyslexia) NO Details______

1 3. SPEECH/LANGUAGE

Is English your native language? YES

If not, what is your first language & how long have you been speaking English? Details ______

As a child were you a late talker or did you have any speech or language difficulties? YES / NO Details: My mother tells me that I was a bit late talking, but not enough that they did anything about it. I was fine by the time I started school

Do you have difficulty with expressing yourself or finding the words that you want to use? YES Details: I often struggle to think up appropriate ways to articulate myself verbally. I sometimes resort to clichés or idioms which can distort the meaning. I have trouble finding the right word when I am talking and have to use alternatives.

4. EDUCATION

As a child, did you have difficulty learning:

To read or spell YES Details: Always in the lowest spelling group at school. Primary school teacher told my parents I was academically average at best – now I would consider myself very strong academically. I couldn’t read aloud fluently until the age of 18.

Did you have difficulty with any areas of Maths (such as learning the times tables, long division, graphs/ tables) YES

Details: Despite being good at the logical mathematics required for advanced calulations (algebra etc) I struggle with times tables and was not considered good at maths until I was 13.

Did you have any difficulties learning French? YES

Details: I had to work very hard to learn vocab and think very carefully about sentence structure. It was not natural to me. I’m not sure if my hearing is good as I found the listening part really hard to understand and spent ages revising all the possible scenarios for the oral exam, so that I would have a chance at getting what was being said.

2 Did you ever have extra tuition for these difficulties? No

If so, for how long & at what age?______

5. LITERACY

Do you have difficulties with planning, organizing or structuring your essays? YES

Details: I always use a computer so that I can edit and correct and insert extra points. I sometimes find it hard see the “correct” way to structure an argument.

Do you read slowly and/or need to re-read to absorb information? YES

Details: I cannot skim read. Read each word individually. Often need to re-read.

Do you have difficulties listening and taking notes simultaneously? YES

Details: Very much so!

6. MOTOR CO-ORDINATION

Did you or other people consider you to be a ‘clumsy’ child? NO

Details: Not especially

Were you able to learn to tie shoelaces or ride a bicycle easily as a child? NO

Details: both fine.

Do you consider your handwriting is slow or lacks legibility ? No

Details: It is neat & I consider it legible – can be a bit slow , but I think that is more about getting the ideas down, than the speed of the writing itself.

Do you tend to knock and spill things? NO

Details: Not especially

3 7. SOCIAL INTERACTION

Do you have difficulty with team work? NO

Details No

Do you have difficulty communicating effectively with other people? YES

Details: Generally no but sometimes can’t express my intentions clearly enough

Do you enjoy social interaction? YES

Details: Generally yes

8. OTHER INFORMATION Please give details of any other information that you think may be relevant. ______