Adult Dyslexia Checklist

1
Name* This field is required.
First Name
Last Name
2
Age Range* 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 think of the physical act of writing as “painful” or “difficult?”* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
6
2. Do you mix lowercase and uppercase letters while writing, use inconsistent spacing between words or lines of text, or switch randomly between print and cursive?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
7
3. Do you feel like you can explain yourself clearly when you’re speaking, but not when you’re writing?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
8
4. Do you avoid writing whenever possible — preferring a grocery list app over a written list, for instance?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
9
5. Do you put off working on writing tasks, procrastinating until the last minute?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
10
6. Is your handwriting hard to read, even for you?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
11
7. Do you attempt to write a ‘perfect’ first draft in order to avoid revisions and rewrites?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
12
8. Are you anxious in social situations, even if you know the people around you?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
13
9. When working on long writing assignments, do you struggle to pull together your thoughts into a well-organized outline?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
14
10. Do you have difficulties cutting food, doing puzzles, or manipulating small objects by hand?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
Other
15
11. Are you told that you hold a pen “strangely” or “awkwardly?”* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
16
12. Do you struggle when reading a map?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
17
13. Do you avoid or dislike drawing, tracing, or painting* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
18
14. Do you make spelling errors, even in words you use often?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
19
15. Do you have trouble filling in forms by hand — at work, for example, or at the doctor’s office?* This field is required.
NEVER
RARELY
SOMETIMES
OFTEN
VERY OFTEN
20
YOUR SCORE
21
If your results show that you may be dyslexic, would like to be contacted to receive further support with dyslexia?* This field is required.
YES
NO
22
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
23
I understand that the result of the checklist only indicates probability of dyscalculia and is not an assessment.* This field is required.
Yes, I understand the is not an assessment but a checklist screening.
Should be Empty: