Thank you for choosing The Dyslexia Center for your evaluation. To provide you with the most accurate evaluation of your abilities, please provide as much of the following information as possible:

Supporting Documentation

Client History

Client Information

Gender

Purpose of Evaluation

What do you hope to learn from this evaluation?

Developmental History (if known)

Are you Adopted
Anything unusual about your infancy?
Term

Milestones

Sitting
Walking
First Words
Clear Speech
Crawling
Skipping/Running
First Sentences

Medical History

Do you have a history of...

Vision and/or Hearing Screenings?
Glasses?
Hearing loss or hearing aids?
Serious illness or injury?
Recurrent ear infections?
Seizures?

Sleep Habits

Do you fall asleep easily?
Do you have any sleep problems?
Do you sleep soundly?

Family History

Please list the members of your immediate family.

Sex
Sex
Sex
Sex
Sex
Sex

Does your family have a history of any of the following?

Dyslexia (or reading/spelling difficulties)
Learning Disabilities
ADHD (hyperactive or inattentive)
Speech/Language Delays
Psychological/Emotional Disorders
Autism/Asperger's
Intellectual Disability
Neurological Diseases

Academic History

Are you...

Able to finish work in class/office?
Able to work independently?
Able to pay attention?
Able to finish homework?
Able to sit still/not fidget?
Able to enjoy school/job?

Academic Performance

Special Education (if applicable)

Retentions
Individualized Education Program (IEP)/Special Education
Individualized Literacy Plan (ILP)
504 Plan
Response to Intervention (RTI)

Evaluation and Therapy History

If you have been evaluated by a specialist in any of the following areas, please indicate below and upload any documentation you may have.

Speech and Language

Occupational Therapy

Physical Therapy

Child Find

Special Education

Psychological/Cognitive

ADHD

Other

Social/Emotional History

Interests, Abilities, Activities