Adult Dyslexia Checklist

1
Name* This field is required.
First Name
Last Name
2
Age* This field is required.
18- 25
26-39
40-55
56-64
over 65
3
Gender* This field is required.
Male
Male
Female
N/A
4
E-mail* This field is required.
example@example.com
5
1. Do you misplace objects around the house or get lost in familiar areas?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
6
2. Do you have trouble estimating how long it will take you to get somewhere, even if you’ve made the trip before?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
7
3. Do you forget math facts that everyone else seems to know, like time tables or common formulas?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
8
4. Do you hear complaints that you drive too fast or too slowly — even though you feel like you drive at a normal speed?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
9
5. Do you arrive late to events or appointments?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
10
6. Do you find it hard to stick to a budget or keep track of your finances?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
Other
11
7. Do you get anxious when you know math-related tasks are coming up — a meeting where you’ll have to discuss your company’s latest quarterly figures, for example?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
12
8. Do you forget phone numbers or addresses, even just a few moments after they were said to you? * This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
13
9. Do you find it difficult to do mental math and find yourself giving incorrect change or calculating a wildly inaccurate tip?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
14
10. Do you have difficulty reading graphs or charts?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
15
11. Do you have trouble telling time on an analog clock?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
16
12. Do you run out of time when completing tasks on deadline, or find that much more time has passed than you had originally thought?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
17
13. Do you have trouble learning athletic movements, dance steps, or anything that requires you to move your body in a certain sequence? * This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
18
14. Do you skip numbers or read a few of them backward when reading a long list? * This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
Other
19
YOUR SCORE
20
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
21
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
22
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: