This is a copy of the questionnaire I had to fill out for the Learning Diagnostic Clinic so I can be retested for my Learning Disability.
Briefly, what problems are you having that brought you here? Identify primary concerns and prioritize them. Discuss details of how long problem has been an issue. How have you tried to correct it?
My primary concern is my poor math skills. This has been a problem all my life. Over time I have developed functional math skills.
What do you hope to get from this evaluation? (e.g., diagnosis, accommodations, tutoring, etc.) I hope to get up to date documentation of my disability, in the hope of getting extra tutoring for Math classes.
Educational History and Career Goal
Briefly, have you ever been diagnosed with or tested for a learning problem, attention deficit or other psychological issue? (Please bring any available records to your first appointment.)
Were you ever held back in a grade? Yes
If yes, which grade(s) and why? 2nd grade I was having a hard time in school for a variety of reasons.
Did you have any problems in grade/elementary school? Yes
Did you have any problems in middle school and/or junior high? Yes
Did you have any problems in high school? No
What grades did you typically make? Cs
What was your high school GPA? 2.74 (I Think)
Were you considered a discipline or behavior problem in school? No
Did your teacher’s always say you were capable of doing better? Yes
Were you ever expelled or suspended? Yes
Did you ever get in any physical fights during school? Yes
Were you ever in any special classes? Yes
Tell me about your college experience.
What is your current GPA?
What is your current course load? N/A
Is that a typical amount? N/A
Are you currently taking any difficult classes? N/A
Have you ever dropped out of college or stopped taking courses? Yes No
What is your career goal? TESOL
Tell me about your reading ability.
Do you read better silently or orally ? Silently
Is reading speed a problem? No
Do you have problems with phonic skills? No
How is your vocabulary? Good
Do you have difficulty with reading comprehension? Yes
Tell me about your spelling ability.
Do you believe you are a good or bad speller? Decent
What types of spelling errors do you make if any? I have the tendency to rely on the spell checker a little too often
Tell me about your writing ability.
How is your grammar? Okay
How is your punctuation? Poor
How is your capitalization? Good
How do you organize your thoughts? I tend to write whatever comes to mind, then go back and edit.
Do you have the ability to develop an idea? Yes
How fluent are those ideas? Good
Tell me about your math ability. (types of errors, reasoning ability)
Are there specific types of errors you make? I am decent in basic math but get flustered with more complicated forms.
How is your reasoning ability? Good
Other Relevant Skills
Do you have any trouble paying attention in class or in general? Yes
If yes, give examples When I am comfortable, I tend to daydream and lose focus.
Do you have any trouble taking notes or understanding the notes you have taken? Yes
Do you have any trouble concentrating on homework or in general? Yes
If yes, give examples I tend to focus for a little bit then will go off and take a break.
How is your memory? Decent
Do you give up easily? Yes
Do you budget your time well? Yes
How are your study habits? They need improvement
Do you consider yourself an organized person? (e.g., uses a planner?) No
Do others consider you an organized person? No
How well do you take tests?
Do you experience test anxiety? Yes
Do you run out of time? No
Do you score poorly on things you thought you knew? Yes
What types of strategies or accommodations are helpful and are any being used regularly?
Do you ask for help? Yes
Do you use a tape recorder in class? No
Do you have a study partner? No
Do you study in a certain location? Yes
Do you study in a certain way? Yes
Developmental and Personal History
Tell me about your birth history.
Was it a Cesarean or vaginal delivery? Vaginal
Were there any complications during birth process? No
Were you premature, late or on time? A day or two late
Did you lose oxygen during the birth process? No
How was your mother’s health during pregnancy? Okay
Did your mother use alcohol or other drugs during pregnancy? Yes
Did your mother smoke cigarettes during pregnancy? Yes
Were your developmental milestones within normal limits? (Average, late, early)
Sitting Up Average
Toilet Training Average
Did your parents claim that you were difficult to control as a child? No
Did you have any problems getting along with your peers as a child? No
Did you have any temperament or mood difficulties as a child? No
Tell me about your home life and family.
Father’s occupation and education? Pest Control, College
Mother’s occupation and education? Medical Transcripts/ College
Parent’s marital status? Widowed
Who raised you? Dad
How was your relationship with your care givers? Good
What was growing up in your family like? Good at times, Sad at others, Very supportive but at the same time isolated.
Number of siblings, ages, and occupations? 1, 30, Maintenance
Tell me about your current relationship with you siblings. Okay
Who currently resides with you? Dad and brother
Length of current marriage if applicable?
Number of times married? 0
Spouse’s occupation and education?
Number of children and ages?
Tell me about your relationships with those who currently live with you. Okay
Tell me about your current relationship with your parents? Good
Are there any other members of your immediate family with learning problems, attention problems, or psychological difficulties? Yes, my Dad has a learning disability
Do you work? Yes
If so, what is your job? Crossing Guard/ Cook
How many hours a week do you work? 42
How long have your worked at this job? 6 and 4 years
What types of work have you done in the past? Clerk
Have you ever been fired? No
Have you served in any branch of the military? No
What are some of your hobbies or interests? Reading, Writing, Crotchet, Painting figurines
Were you healthy child? Yes
Did you suffer from chronic ear infections? (at what age and were tubes inserted?) No
Do you have any ongoing or chronic health problems (including allergies)? Yes
Do you sleep okay? Yes
How much sleep do you obtain on average? 7 to 9 hours a night
Please describe any sleep-related problems. N/A
How is your appetite? Good
Describe any significant illnesses, hospitalizations, or injuries. (Be sure to describe what happened and when.)
Have you ever had any heart problems? No
Have you ever had high blood pressure? No
Have you ever had migraine headaches? No
Have you ever had a thyroid condition? No
Were you ever in a car accident (even if you don’t believe you were hurt)? Yes
If yes, please describe.
It was a rainy night and my Dad accidentally pulled out in front of another car, we got sideswiped. Fortunately, we always wear seatbelts so were only shaken about. The other people were not injured.
Have you ever been unconscious? No
If yes, please describe this.
Have you ever had a seizure for any reason? No If yes, please describe.
Tell me about your past and current use of alcohol. I drink with friends. About, two or three times a year I get really drunk.
Tell me about your past and current use of illicit drugs. I have never done drugs but I have gotten a bit contact high
Have you ever had any problems with alcohol or drug abuse? No
Have you ever been treated for alcohol or drug problems? No
Have you ever had a psychological problem? (e.g., depression, anxiety, etc.) No
Please describe the problem(s) and identify when and for how long they occurred.
Have you ever seen a psychologist, counselor, etc. to deal with emotional or psychological issues? No
Was any help he/she received beneficial?
Have you ever been hospitalized for a psychological problem? No
Are there any significant stresses in your life right now? Yes
How would you describe your mood most of the time? Okay
Do your moods change very frequently, abruptly or unpredictably? No
Do you have excessive fears or phobias? No
Do you have any obsessions or preoccupations? No
Have you ever had a panic attack? No
Do you have any compulsive habits or rituals? Yes
Have you ever experienced a delusion? No
Have you ever experienced a hallucination? No
Do you have problems with gambling? No
Do you have an eating disorder? No
Do you have trouble making friends? Yes
Do you have trouble keeping friends? No
Do you have any sexual difficulties? Yes
Do you often lose your temper? No
Do you often argue with others? No
Do you defy or refuse to comply with supervisor’s request or rules? No
Do you deliberately annoy people? No
Do you blame others for your mistakes? No
Are you touchy? No
Are you angry and resentful? No
Are you spiteful or vindictive? Yes
Do you bully, threaten or intimidate others? No
Do you initiate physical fights? No
Have you ever used a weapon that caused physical harm to others? No
Have you been physically cruel to people? No
Have you been physically cruel to animals? No
Have you stolen while confronting the victim? No
Have you forced someone to sexual activity? No
Have you engaged in fire setting? No
Have you deliberately destroyed other’s property? No
Have you broken into somebody else’s house, building or car? No
Do you often lie? No
Have you stolen items of non trivial value? No
Did you run away as a child? No
Did you skip school? Yes
Are you impulsive or do you fail to plan ahead? Yes
Have you ever had trouble with anxiety? No
If you have anxiety, do you find it difficult to control the worry? No
Do you feel restless, keyed up or on edge? Yes
Are you easily fatigued? Yes
Does your mind go blank? Yes
Are you irritable? Yes
Do you suffer from muscle tension? Yes
Do you feel sad or empty? No
Have you lost interest or pleasure in activities? No
Have you had any significant weight gain or lose in the last month? No
Do you feel worthless? No
Do you feel guilty? No
Are you indecisive? Yes
Have you had any recurrent thoughts of death? Yes
Have you considered suicide? No
Have you attempted suicide? No
Do you have a specific plan for committing suicide? No
What medications do you take regularly or often? Please give the name of each medication, the purpose, and the dosage.
Is there anything else about you that you think we should know? N/A