Screening Questionnaire

1. Name of the child.................................................................

2. Date of birth....................... Age/Sex..................

3. Completed by:........................ (Name)........................................ (Relation)..........................

4. Grade:

5. School:

6. Areas of Strength:

1. MOTOR SKILLS NEVER SOMETIME ALWAYS DON’T

S KNOW
Does your child exhibit problems with
balance?
Does your child tire easily while playing
outdoor games?
Does your child often complain of pain in
joints/muscles?
Does your child prefer stooped/faulty
posture?
Does your child seem
clumsy/disorganised while playing?
2. DAILY ACTIVITIES
Does he/she get confused with left and
right shoes/footwear/difficulty to lace
shoes?
Does he/she need prompting to do their
routine tasks?
Time management(Is he/she able to
complete activities/ assignments on
time?
 Yes No Dependent With
supervision
Time management (Is he/she able to
complete activities/assignments on
time?)
3. READING Never Sometimes Always Don’t know

Does he/she have difficulty pronouncing

words?
Does he/she omit/substitute/add words
while reading?
Does he/she ignore punctuation?
Does he/she make reversals of
words/letters while reading?
Does he/she read too fast/to slow?
4. WRITING/SPELLING/COPYING Never Sometimes Always Don’t know
Does he/she have difficulty in
remembering phonic sound?
Does he/she have difficulty listening to
words?
Does he/she ignore vowel sounds while
writing?
Does he/she have excessive overwriting?

Does he/she write very big letters/very

small letters?
Does he/she omit/add letters/ words
while copying?
Does he/she ignore punctuation?
Does he/she have reversals of
letters/words?
Does he/she mix up capital/small letters?
5. AUTHENTIC COMPUTATION Never Sometimes Always Don’t know
Does he/she have difficulty identifying
symbols/numbers?
Does he/she have errors in place value,
time concept, calendar etc.?
Does he/she have difficulty in basic
operations (addition, subtraction,
multiplication, division)
Does he/she have errors while
transferring from rough to fair work?
Does he/she have errors in graded
arithmetics (fractions, decimals)
Does he/she require assistance in solving
story sums (word problems)?
 6. BEHAVIOURAL AND SOCIAL Never Sometimes Always Don’t know
Is your child argumentative?
Does he/she follow rules and regulations?
Does your child interrupt other
children/teacher during class hours?
Does he/she forget/lose things?
Is he/she able to narrate/describe certain
events?
Does he/she have peer interaction?
Does your child easily get angry with
failures?
7. SPEECH, LANGUAGE AND HEARING Never Sometimes Always Don’t know
Does he /she ask for repetition?
Does he /she repeat sounds or words
frequently while talking?
Is he/she able to stick to the topic while
talking?
Is he/she able to express events or narrate
stories without difficulty?
Does he /she have difficulty in producing
certain speech sounds?
Does he /she find it difficult to understand
speech/language?

Feedback from school:

Specify your concern:

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Your valuable feedback:

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