Middle Tree Dyslexia Program Pre-Screening Parent Questionnaire

Parents, this questionnaire helps us determine if a dyslexia screening is appropriate for your student. Please feel free to add details and explanations to your answers. All answers will remain confidential. Please work with your School Nurse or SST Coordinator in completing this form if you need assistance. Thank you!

Child's Name:

Child's School:

Child's School District:

Child's Grade:

Child's Age:

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Choice AChoice BChoice C

Does the student already have an IEP for any of the following reasons?

Communication DisorderReceptive or Expressive Language DisorderUnintelligible SpeechDevelopmental Delay, Cognitive IssuesSocial/Emotional or Behavioral Challenges

Has the student had occupational therapy for gross motor skills?

YesNo

Has the student had a vision and a hearing test within the last 18 months?

YesNo

If yes, what were the results?

Were there any problems/complications during pregnancy? If yes, please explain. (Significant alcohol use during pregnancy? Illegal drug use during pregnancy? Maternal illness or medical conditions during pregnancy?)  

Was the student born prematurely or were there difficulties during the birthing process? If yes, please explain. (Low Apgar scores, low birth weight, neonatal ICU, etc.) Did the baby leave the hospital at the same time as the mother? If not, why not?

Was the child adopted from a foreign country? If yes,

Was the child in an orphanage prior to adoption? In what country?  Was the child adopted after 3 years of age?  Did the child suffer from malnutrition?  Did the child have any significant medical or developmental delays?  Was there any suspected alcohol or drug abuse during pregnancy?

Has the student ever had seizures (other than 1 or 2 seizures caused by high fever)?

YesNo

Is there any reason to suspect brain injury or brain damage?

YesNo

Is there any reason to suspect cognitive delay?

YesNo

Does the student have any of the following?

difficulty maintaining eye contact

difficulty maintaining his/her balance when playing

unusual difficulty understanding jokes and common sayings

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