1. Do you have a bad memory for names?
     Yes   No    Not Sure


2. Is it hard to read unfamiliar words?
     Yes   No    Not Sure


3. Is spelling words you haven't seen written down before difficult?
     Yes   No    Not Sure


4. Have you ever had a problem telling right from left?
     Yes   No    Not Sure


5. Do you sometimes forget how to spell short words you know well?
     Yes   No    Not Sure


6. Do you use and understand complex words that you would be unable to spell?
     Yes   No    Not Sure


7. Does reading make you tired quickly?
     Yes   No    Not Sure


8. When you're reading do the words appear to be blurred, moving or hard to focus on?
     Yes   No    Not Sure


9. Generally, do you make a lot of errors when reading?
     Yes   No    Not Sure


10. When your eyes are moving across text do they feel slightly out of coordination?
     Yes   No    Not Sure


11. Do you often find yourself thinking of something else when reading?
     Yes   No    Not Sure


12. Do you find yourself getting fixated on a word you can't read?
     Yes   No    Not Sure


13. Have you ever had a habit of pronouncing words incorrectly in speech?
     Yes   No    Not Sure


14. Is maintaining concentration a problem?
     Yes   No    Not Sure

Total: