Dyslexia Support Team

Specific Learning Difficulties Questionnaire

For students who believe they may be dyslexic, or may have another
specific learning difficulty

Please ONLY complete this questionnaire if you have never been assessed
for dyslexia or another specific learning difficulty, or the assessment
report is no longer available. Please complete the form by hand.

The Dyslexia Support Team need this information to help understand the nature of
your difficulties. It is important that you answer as fully as possible
otherwise this may delay your referral. This questionnaire will be treated as
confidential.

Please note if you are a final year student, depending on when we receive this
form, we may not have sufficient time to carry out a Screening Test.

Name

NTU ID number

Mobile Number

Email address

Course

Year of study

Is this your final

year?

For fee purposes, are you classed as a:

UK/Home student
EU Student
International student

Please use this section to give full details about your reasons for
contacting the Team: (this section must be completed, if it is not this may
delay your referral)

________________________________________________________________

________________________________________________________________

________________________________________________________________

Have you ever had an assessment for dyslexia, or another specific learning
difficulty?

Yes No
 If yes, what was the result of the assessment? _______________

______________________________________________________________

______________________________________________________________

 Give an approximate date when this assessment occurred ____________ and

please enclose a copy of the report.

If you do not have a copy, please contact your previous school or college to
obtain this. If you have never had an assessment for dyslexia, or the report is no
longer available, and you would like to be considered for a Screening Test please
complete the following questions.

Reasons for Dyslexia Adult Screening Test (DAST)

What feedback or comments have you received on your work from your academic
tutors? Please indicate coursework marks and/or exams if appropriate.

__________________________________________________________________

__________________________________________________________________

What makes you think you might be dyslexic or have another specific learning
difficulty?
__________________________________________________________________

__________________________________________________________________
Have you experienced your difficulties for a long time? If yes please give full
details:

__________________________________________________________________

__________________________________________________________________

Has anyone in your family been formally assessed as dyslexic?

__________________________________________________________________

__________________________________________________________________

Why do you want an assessment for dyslexia (or another specific learning
difficulty)?

__________________________________________________________________

__________________________________________________________________

What have you done to address the problems you are experiencing and improve
your work e.g have you accessed support from the student mentors, or attended
the Academic Workshops?
__________________________________________________________________

__________________________________________________________________
School History

Primary Schooling (5 – 11 years old)

Did you have problems learning to read? Yes No

Did you have problems learning to spell? Yes No

Did you receive extra help? Yes No

Please give details of the help received ____________________________

Were there any disruptions/did you miss school? Yes No

Is English your first/main language? Yes No

If no, what is your first/main language? _______________________________

Secondary schooling (11 – 16/18 years old)

Were your problems recognised by your school? Yes No

Did you receive extra time in exams? Yes No

If yes please obtain evidence of this from your previous school/college

Did you receive extra help? Yes No

Please give details of the help received____________________________________

Did you receive any other support e.g.

Reader Transcript

Amanuensis Use of laptop

Exams Passed – please give full details

GCSE (or equivalent): Grade Grade Grade

English Language Art Other
English Literature D/T _____________
Science (Double) Computing Other
Biology Foreign language _____________
Physics Religious Studies
Chemistry History
Maths Geography
PE Drama
A2 Level (or equivalent):

Subject 1 ________ Grade _______Subject 2 ________Grade_______

Subject 3 __________Grade _______Subject 4________Grade_______

If you are a European or International student, please give details of your

equivalent exams.
Other college/educational experiences since leaving school:

__________________________________________________________________

__________________________________________________________________

Work related qualifications:

__________________________________________________________________

__________________________________________________________________

Background history

Are you aware of there having been any unusual complications at birth?

Yes No

Did you suffer from ear infections/glue ear (primary school)?

Yes No

Have you or do you experience any vision problems: squint/lazy eye/other?

Yes No

Have you or do you experience any motor coordination problems (e.g. tying
shoelaces/catching a ball or ‘clumsy child’ syndrome)?

Yes No

Did you experience any speech or language difficulties/’late talker’?

Yes No

Do you suffer from any health problems that may affect your learning?
Yes No

If you have ticked yes to any of the above please give full details

__________________________________________________________________

__________________________________________________________________

Do you have trouble listening?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you lose concentration/switch off quicker than other people?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have trouble pronouncing long words e.g. statistical?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have difficulty thinking of words in conversation?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have problems with listening and taking notes at the same time?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you think you have reading difficulties? Yes No

Do you need to re read text frequently to understand it? Yes No

Do you have oral difficulties? Yes No

Do you have problems keeping your place when reading? Yes No

Does the print ‘dance’ or blur or irritate the eyes? Yes No

Do you seem to take longer reading than other people? Yes No

Do you have difficulty getting ideas down on paper?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have problems with grammar/sentence structure/punctuation?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have problems with spelling?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have problems with organisation and planning?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Have you had any help with your written work? Yes No

If yes, please indicate what help you have received e.g. family/friends read work,
support tutor, other:

__________________________________________________________________

__________________________________________________________________

Does your work vary a lot?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have difficulty remembering what words look like?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Did you have difficulty learning your times tables?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Do you have difficulty doing sums in your head?

No  (little problem) 1 2 3 4 5 Yes  (big problem)

Can you do maths with a calculator? Yes No

How would you describe your memory?

 (good) 1 2 3 4 5  (poor)

Please describe:

__________________________________________________________________

__________________________________________________________________

Have you passed your driving test? Yes No

How many times did it take you to pass your driving test? _________________

Did you have difficulty learning to tell the time using a clock face? Yes No

Do you get lost easily? Yes No

Do you have map reading difficulties? Yes No

Do you experience left/right confusion? Yes No

Other:
__________________________________________________________________

__________________________________________________________________

Do you have difficulty copying (from a whiteboard etc)? Yes No

Do you reverse letters? Yes No

Does your hand get tired after a short period of writing? Yes No

Thank you for taking the time to complete this form.

Please return this form to the Enquiry Desks at:

 Student Services Centre, Central Court, Newton Arkwright Building, City
Campus
 Student Centre, George Eliot Building, Clifton Campus
 Student Centre, Bramley Building, Brackenhurst Campus

Postal address:
Dyslexia Support Team, Student Support Services, Nottingham Trent University,
Burton Street, Nottingham, NG1 4BU

Contact details for the Dyslexia Support Team:

0115 848 4120
dyslexia.support@ntu.ac.uk
www.ntu.ac.uk/dyslexia