Pre-screening Questionnaire

A Brain Sprints Neurodevelopmental Screening helps you understand the root causes of learning challenges for ages 5+. A Screening focuses on a few key areas of brain development. It helps identify blocks related to academics and behavior in these areas:

1. Auditory short-term memory: related to the use of phonics to read, ability to follow directions, attention, social maturity, reading comprehension, and math word problems.

2. Visual and auditory long-term memory: where is information stored so there is easy access to what was taught.

3. Eye teaming: how are the eyes tracking and working together to give good visual information to the brain for reading and writing.

4. Lower-level brain development: the foundation of all learning, affecting organized behavior and thinking, and much more.

Identifying needs in these key areas make a screening a valuable starting point in becoming equipped to address inefficiencies so learning will be easier.

Parent or Guardian Name:

First NameLast Name

Cell Phone Number

Area CodePhone Number

Date

MonthDayYear

City, State

E-mail

Location of Screening

Coupon Code:

Where did you hear about us?

Have you done a phone consultation with us?

Name of Screening Participant:

First NameLast Name

Participant's Date of Birth:

MonthDayYear

School Attending

Participant's grade level:

Current reading grade level

Current math grade level

Rate the mastery of math facts

Rows	Poor	Average	Good	Not Yet introduced
Addition
Subtraction
Multiplication
Division

Hand Dominance:

Did the participant take a long time to choose their dominant hand?

Other

Did you ever think this individual was going to use the opposite hand he/she uses now?

Other

Does the individual have any blood relatives that are ambidextrous or left handed? Check all that apply.

Please indicate the level of concern of the participant's abilities in the following areas:

Rows	No Concern	Mild Concern	Moderate Concern	Strong Concern
Word Recognition
Reading Comprehension
Ability to use phonics
Immediate Recall of Math Facts
Math Computation
Logical Thinking
Following Directions
Attention Span
Conversational Language
Social Maturity
Short Term Memory
Long Term Memory
Overall Organization
Letter Reversals
switches from right to left hand often

Please indicate any other concerns:

Has the participant been given any labels?

If so, please include labels below:

Would the participant cooperate willingly by doing activities asked of a stranger? (You will be in the room, too.)

Does the participant need help with mobility (i.e. crutches, walker, wheelchair)?

Good days and times for online screening (this is for zoom screenings only)