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: