VMB Development, Inc. NonProfit 501(c)(3)
Learning & Living Challenges, Inabilities, Struggles with Questionnaire
Ask yourself the following questions and select one of the following three answers:
Does your child struggles with.........
Aggresiveness:
NEVER
SOMETIMES
A LOT
Anger Control:
NEVER
SOMETIMES
A LOT
Anxiety:
NEVER
SOMETIMES
A LOT
Asking What or Huh A Lot:
NEVER
SOMETIMES
A LOT
Attention:
NEVER
SOMETIMES
A LOT
Balance:
NEVER
SOMETIMES
A LOT
Behavior:
NEVER
SOMETIMES
A LOT
Blocking Out Background Noise:
NEVER
SOMETIMES
A LOT
Bright Lights:
NEVER
SOMETIMES
A LOT
Catching or Throwing A Ball:
NEVER
SOMETIMES
A LOT
Changes Or Surprises:
NEVER
SOMETIMES
A LOT
Clothes Sensitivity:
NEVER
SOMETIMES
A LOT
Clumsiness:
NEVER
SOMETIMES
A LOT
Comprehension:
NEVER
SOMETIMES
A LOT
Communication Skills:
NEVER
SOMETIMES
A LOT
Concentration:
NEVER
SOMETIMES
A LOT
Coordination:
NEVER
SOMETIMES
A LOT
Chores Being Completed:
NEVER
SOMETIMES
A LOT
Distractions:
NEVER
SOMETIMES
A LOT
Diziness:
NEVER
SOMETIMES
A LOT
Emotion Control:
NEVER
SOMETIMES
A LOT
Enough Energy To Complete What They Are Doing:
NEVER
SOMETIMES
A LOT
Eye Movement Control:
NEVER
SOMETIMES
A LOT
Fear:
NEVER
SOMETIMES
A LOT
Fidgetiness:
NEVER
SOMETIMES
A LOT
Focusing Equally With Both Eyes:
NEVER
SOMETIMES
A LOT
Focusing & Thinking At The Same Time:
NEVER
SOMETIMES
A LOT
Following Instructions:
NEVER
SOMETIMES
A LOT
Forgetfulness:
NEVER
SOMETIMES
A LOT
Hand/Eye Coordination:
NEVER
SOMETIMES
A LOT
Handwriting Ability:
NEVER
SOMETIMES
A LOT
Holding On To Something:
NEVER
SOMETIMES
A LOT
Impulsiveness:
NEVER
SOMETIMES
A LOT
Interacting With Others:
NEVER
SOMETIMES
A LOT
Knowing Which Is Left and Which is Right:
NEVER
SOMETIMES
A LOT
Learning Ability or Willingness:
NEVER
SOMETIMES
A LOT
Letter or Word Pronunciation:
NEVER
SOMETIMES
A LOT
Letter or Number Reversal, Backwards or Upside Down:
NEVER
SOMETIMES
A LOT
Listening:
NEVER
SOMETIMES
A LOT
Long Term Memory:
NEVER
SOMETIMES
A LOT
Loud Noises:
NEVER
SOMETIMES
A LOT
Math:
NEVER
SOMETIMES
A LOT
Melt Downs:
NEVER
SOMETIMES
A LOT
Messy Eating:
NEVER
SOMETIMES
A LOT
Motion Sickness:
NEVER
SOMETIMES
A LOT
Motivation:
NEVER
SOMETIMES
A LOT
Motor Skills:
NEVER
SOMETIMES
A LOT
Multi Tasking Ability (Listen/Think/Move/Speak At The Same Time):
NEVER
SOMETIMES
A LOT
Mood Swings:
NEVER
SOMETIMES
A LOT
Organizational Skills:
NEVER
SOMETIMES
A LOT
Patience:
NEVER
SOMETIMES
A LOT
Physical Activity Ability or Willingness:
NEVER
SOMETIMES
A LOT
Picky Eater:
NEVER
SOMETIMES
A LOT
Playing or Doing Things With Others:
NEVER
SOMETIMES
A LOT
Poor Posture:
NEVER
SOMETIMES
A LOT
Processing Visual Pictures In Mind:
NEVER
SOMETIMES
A LOT
Reading:
NEVER
SOMETIMES
A LOT
Receiving & Processing Sounds:
NEVER
SOMETIMES
A LOT
Retaining What Was Learned:
NEVER
SOMETIMES
A LOT
Self Confidence:
NEVER
SOMETIMES
A LOT
Speech:
NEVER
SOMETIMES
A LOT
Sense of Sound:
NEVER
SOMETIMES
A LOT
Sense of Smell:
NEVER
SOMETIMES
A LOT
Sense of Sight:
NEVER
SOMETIMES
A LOT
Sense of Taste:
NEVER
SOMETIMES
A LOT
Sense of Touch:
NEVER
SOMETIMES
A LOT
Spelling:
NEVER
SOMETIMES
A LOT
Short Term Memory:
NEVER
SOMETIMES
A LOT
Sleeping Through The Night:
NEVER
SOMETIMES
A LOT
Social Situations:
NEVER
SOMETIMES
A LOT
Stress:
NEVER
SOMETIMES
A LOT
Swimming:
NEVER
SOMETIMES
A LOT
Temper Tantrums:
NEVER
SOMETIMES
A LOT
Tension in Jaw:
NEVER
SOMETIMES
A LOT
Thinking:
NEVER
SOMETIMES
A LOT
Tiredness:
NEVER
SOMETIMES
A LOT
Understanding What Was Said or Shown To Them:
NEVER
SOMETIMES
A LOT
Visual Perception:
NEVER
SOMETIMES
A LOT
Walking With Feet Turned Inward Or Outward:
NEVER
SOMETIMES
A LOT
Whining Episodes:
NEVER
SOMETIMES
A LOT
Willingness To Do or Try New Things:
NEVER
SOMETIMES
A LOT
Date
-
Month
-
Day
Year
Date
Child Name
First Name
Last Name
Parent Name
First Name
Last Name
Email
example@example.com
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: