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Part II  -  Symptom Profile Form
 

      Student Name:_________________________________ 

Fill out this form to rate your child in the abilities listed below.  Use the following guide:

5-superior  4-good   3-average  2-below average  1-severe

Attention Span: This is the ability to do close-eye work for at least 20 to 30 minutes.  This would include desk work, reading, etc.

5             4             3             2             1

Comprehension: This is the ability to remember what is read, retain information, recall facts and memorize.

5             4             3             2             1

Concentration: This is the ability to stay on task without distraction.

5             4             3             2             1

Reading Skills: This is the ability to read smoothly across a page without choppy, slow, or laborious effort.  This includes an ability to read without hesitations, skipping, or miscalling words.

5             4             3             2             1

Handwriting: This is the ability to write neatly, evenly spaced, and with organization.

5             4             3             2             1

Spelling: This is the ability to spell, retain words in long-term memory, and write words without reversals or transposed letters.

5             4             3             2             1

Following Directions: This is the ability to follow written or spoken directions and correctly sequence information.

5             4             3             2             1

Please check (click) each box that your child experiences regardless of frequency of occurrence:

Complains of discomfort in eyes when writing, drawing,
cutting, etc. Complains of headaches after reading or writing  Tiredness in eyes, excessive blinking, or watery eyes  during school Head turns when reading or tilts head when writing  Loses place often; needs finger to keep place    Displays short attention span when reading  Too frequently omits words, word parts, or numbers   Rereads or skips lines when reading  Misaligns numbers in columns  Writes crookedly, poorly spaced  Mistakes words with similar beginnings  Fails to recognize same word in next sentence    Reverses letters and/or words when reading or writing Fails to comprehend what was read  Errors in copying from the board, overhead, or a book  Slow, choppy, mechanical reading  Inability to follow directions  Unusually tired or fatigued at the end of the school day Poor spelling ability  Avoids reading, homework, or close-eye activity  Lack of long-term memory

End of Part II:  Symptom Profile Form

Please continue to the In-Home Evaluation, click here.

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