Adult Dyslexia Checklist

1
Parent's Name* This field is required.
First Name
Last Name
2
Child's Age* This field is required.
6
7
8
9
10
11
12
13
14
15
3
Gender* This field is required.
Male
Male
Female
N/A
4
E-mail* This field is required.When you are finished taking the quiz. Please check your junk email for your report
example@example.com
5
1. As a young child, did your child struggle to learn to count?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
6
2. Does your child struggle to sort objects by shape, color, or size?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
7
3. Does your child not seem to understand the connection between the symbol “4” and the word “four?” Does he/she make mistakes when reading or following directions involving number words and symbols?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
8
4. Does your child get unnaturally upset or complain of feeling ill while completing math homework?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
9
5. Does your child say numbers out of order — long after peers have mastered this skill?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
10
6. Does your child have difficulty telling time on an analog clock?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
Other
11
7. Does your child struggle to connect the concept of numbers to real-world items? When you ask him/her how many cookies are left, for example, does he/she seem confused by the question or answer incorrectly?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
12
8. Does your child have difficulty applying fractions to real-world objects? Is she unable to determine that a dollar equals four quarters, for instance, or that one-half of the year is equal to six months?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
13
9. Does your child still count on his fingers past third grade?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
14
10. Does your child seem disinterested in keeping score or playing any game that involves math, however indirectly?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
15
11. Does your child not seem to understand the difference between adding and subtracting? Does she confuse the + and – symbols when completing math problems?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
16
12. Does your child struggle to read graphs or charts without help?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
17
13. Does your child get lost, even in familiar surroundings?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
18
14. Does your child have difficulty writing numbers clearly or keeping his work neat when solving math problems?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
Other
19
15. Does your child struggle to understand money, and have difficulty making change or sticking to a budget?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
20
16. Does your child have trouble solving word problems or multi-step math problems? Does she struggle to articulate what strategies she’ll use along the way?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
21
YOUR SCORE
22
If your results show that you may be dyscalculia, would like to be contacted to receive further support with dyscalculia?* This field is required.
YES
NO
23
It is important to remember that this test does not constitute an assessment of one’s difficulties. It is just an indication of some of the areas in which you or the person you are assessing may have difficulties.

However, this questionnaire may provide a better awareness of the nature of an individual’s difficulties and may indicate that further professional assessment would be helpful.

YOUR RESULTS WILL BE EMAILED TO YOU IMMEDIATELY.

PLEASE CHECK YOUR JUNK EMAIL, IF THE EMAIL WITH YOUR RESULTS FAILS TO ARRIVE IN YOUR INBOX
24
I understand that the result of the checklist only indicates a probability of dyscalculia difficulties and is not an assessment.* This field is required.
Yes, I understand the is not an assessment but a checklist screening.
Should be Empty: