Adult booking form

This is a confidential pre- assessment form for adults post 16 years. If you have any difficulties completing this form, please contact Grove Dyslexia for guidance. Please do not complete this before you have been in contact to arrange an assessment.

Use a coloured overlay!

Full name Date of birth Age Country of birth Date moved to the UK (if applicable) Are you adopted? What are your pronouns

Address

Country Address line 1 Address line 2 City/Town Postcode

Contact

Phone Email

Reasons for assessment

What are your reasons for this assessment?

Health and development History

Did you meet all the normal developmental milestones ?

e.g. walking, talking, riding a bike?

Have you ever seen any other specialists (e.g. speech specialists) or been assessed for learning difficulties such as dyslexia?

e.g. Understanding words, expressive language or pronounciation.

Have you ever suffered from any serious illnesses? (Including mental heath difficulties) Is your hearing within normal limits? Are you taking any regular medication that may be relevant?

Vision and Visual Difficulties

It is essential that you have had a sight test within the last 2 years. If you have not, please make an appointment with an optometrist and return to this form when the eye test has been completed.

In some cases, difficulties with reading are caused by visual difficulties that are not related to learning. Therefore, if you have answered yes, you will need to discuss this with your Optician (Optometrist) prior to requesting an the assessment to see if an onward referral is required.

Have you had any history of visual difficulties/problems with sight/visual impairment? Please give the date of the sight test

Was any prescription made?

Yes No

If yes, were you advised to wear the prescription glasses/contact lenses for distance (e.g. for watching television or for driving) or near (e.g. reading) or both?

Distance Near Both

Do you wear glasses? (If you do, please bring them with you to the assessment)

Yes No

Have you ever used coloured overlays or precision tinted lenses?

Yes No

If yes, please provide the following information

Who recommended and provided these? Why were they recommended? Did they help?, if yes in what way? Do you still use them? If not why not?

Visual difficulties

Please consider the following when completing the section below. This section is designed to determine whether symptoms occur frequently. Therefore, if a symptom is experienced infrequently - such as rarely, occasionally, sometimes, or fewer than 2-3 times per month - please respond with ‘No.’

Do you often get headaches when you read or study?

Yes No

Do your eyes often feel sore, or gritty, or watery?

Yes No

Does reading from white paper or from a bright screen often feel uncomfortable?

Yes No

Does the print, or book, or screen, often appear blurred, or go in and out of focus when you are reading?

Yes No

Does the print, or book, or screen, often appear double, or go in and out of focus when you are reading?

Yes No

Do words often seem to move or merge together when you are reading?

Yes No

Do objects in the distance often appear more blurred after you have been reading?

Yes No

Do you often have to screw up your eyes to see more clearly when you are reading?

Yes No

Do you experience any other problems with your vision that interfere with your ability to read or study?

Yes No

If yes, Please describe

In some cases, difficulties with reading are caused by visual difficulties that are not related to learning. Therefore, if you have answered yes, you will need to discuss this with your Optician (Optometrist prior to requesting an assessment to see if an onward referral is required.

Family History

Please indicate whether any other family members experienced difficulties with reading/writing /spelling/general learning or were ever diagnosed with a Specific Learning Difficulty.

Language and Linguistic History

Is English your first language?

Yes No

If not, please provide futher details

Educational History

Which Secondary School did you attend? What were the subjects you were not so good at ? How old were you when your difficulties were first noticed?

Have you received support for any of the following

Did you have a good relationship with your teachers?

Yes Neutral No

Did you work as hard in school as you might have done?

Yes Neutral No

Did you have any specialist support at school? Was your schooling disrupted in any way? What qualifications did you leave school with?

Did you have any difficulties at school with any of the following?

Reading

None Mild Moderate Severe

Writing

None Mild Moderate Severe

Spelling

None Mild Moderate Severe

Maths

None Mild Moderate Severe

Sports and games

1:1 in school Private tutor Small group Whole class

Work History

If you are currently working, What is the name of your employer? Do you currently experience any difficulties at work? Please give details of any previous work you have done? Are you currently studying? Please give details Please outline any difficulties you are experiencing with studying? Please outline any other courses you have taken since leaving school?

Current situation

Please explain why you would like an assessment

Please indicate the areas where you have problems:

Literacy

Identifying the sounds in words Reading aloud Reading quickly Keeping place while reading Reading fluently and accurately

Comprehension

Understanding what you have read Understanding text without re-reading

Listening Skills

Understanding what people are saying Understanding people without needing things repeated

Writing

Spelling

Spelling correctly Spelling 'easy' words when filling in forms in front of others Missing out little words or the ending of words Using words you can't spell

Memory, Attention and Concentration

Remembering new information/instructions Keeping concentration Multiplication tables or sequencing activities Finishing tasks Focussing on writing for extended periods Remembering sequences of letters or nunbers like phone numbers or car registrations

Communication

Thinking of the words to express yourself Losing track of what to you want to say Keeping track of what others are saying Interpreting information correctly Speaking or reading aloud in public Passing on messages accurately

Number, Estimation and Calculation

Remembering mathematical operations Calculate without a calculator Managing day to day finances

Motor skills

Social and Communication skills

In day to day experiences at work, or on any courses you have taken, have you had difficulties with any of the following:

Are there any social situations when you do not feel confident or feel uncomfortable? Do you have any difficulties developing good working relationships? If yes, why?

Do you have any difficulty developing friendships?

Yes Neutral No

Do you find it hard to make eye contact with people?

Yes Neutral No

Strengths

Please outline any strengths you have, what you enjoy doing in your spare time and things that you are good at

Additional information

Did you have any help to complete this form? Do you receive assistance with day-to-day living, for example, from a carer? Have you ever been told you have, or been diagnosed with, a learning disability, e.g. moderate learning difficulty, severe learning difficulty, or global learning difficulty? Do you receive the Personal Independence Payment (PIP)? Please summarise your difficulties and say if there is anything you would like help with in particular. Have any strategies worked for you so far? For example, when planning your work do you mostly think in pictures or words or both? Any other information not covered within this form that we should know before the assessment

Signed

Signed Date completed