<p> CONFIDENTIAL PRE-SCREENING QUESTIONNAIRE</p><p>1. PERSONAL INFORMATION</p><p>Name: Jane</p><p>Date of Birth: DD/MM/YY</p><p>College: X College</p><p>Course: Natural Sciences</p><p>Year: year X (undergraduate)</p><p>Email: [email protected]</p><p>2. BACKGROUND</p><p>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”.</p><p>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.</p><p>Have you had any test in the past for a specific learning difficulty (such as dyslexia) NO Details______</p><p>1 3. SPEECH/LANGUAGE</p><p>Is English your native language? YES </p><p>If not, what is your first language & how long have you been speaking English? Details ______</p><p>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 </p><p>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. </p><p>4. EDUCATION</p><p>As a child, did you have difficulty learning:</p><p>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.</p><p>Did you have difficulty with any areas of Maths (such as learning the times tables, long division, graphs/ tables) YES </p><p>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.</p><p>Did you have any difficulties learning French? YES</p><p>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. </p><p>2 Did you ever have extra tuition for these difficulties? No</p><p>If so, for how long & at what age?______</p><p>5. LITERACY</p><p>Do you have difficulties with planning, organizing or structuring your essays? YES</p><p>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.</p><p>Do you read slowly and/or need to re-read to absorb information? YES</p><p>Details: I cannot skim read. Read each word individually. Often need to re-read.</p><p>Do you have difficulties listening and taking notes simultaneously? YES </p><p>Details: Very much so!</p><p>6. MOTOR CO-ORDINATION</p><p>Did you or other people consider you to be a ‘clumsy’ child? NO</p><p>Details: Not especially</p><p>Were you able to learn to tie shoelaces or ride a bicycle easily as a child? NO</p><p>Details: both fine.</p><p>Do you consider your handwriting is slow or lacks legibility ? No</p><p>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. </p><p>Do you tend to knock and spill things? NO</p><p>Details: Not especially</p><p>3 7. SOCIAL INTERACTION</p><p>Do you have difficulty with team work? NO</p><p>Details No</p><p>Do you have difficulty communicating effectively with other people? YES </p><p>Details: Generally no but sometimes can’t express my intentions clearly enough</p><p>Do you enjoy social interaction? YES</p><p>Details: Generally yes </p><p>8. OTHER INFORMATION Please give details of any other information that you think may be relevant. ______</p><p>4</p>