CONFIDENTIAL
PRE-SCREENING FORM

Please try to fill this in as fully as possible, so as to help us understand you better. Please don’t worry about your spelling or handwriting: we need to see your difficulties and strengths.

You may complete this on your computer or you can print out the form and complete it by hand.

Section 1: PERSONAL DETAILS
My name:
Date of birth:
NUIMemail address:
Student Registration Number:
Contact address and mobile number:
Have you ever been assessed for a learning disability before? If yes by whom?
Section 2: CURRENT COURSE DETAILS
Have you taken any other courses or got any qualifications since leaving school?
What are you studying at the moment?
What year are you in?
How long is your course?
Are you enjoying your course?
Section 3: SCHOOL EXPERIENCES
At school, did you have difficulties with the following activities? TickNO, SLIGHT or YES for each activity.
Activity / NO / SLIGHT / YES
Reading

Spelling

Handwriting
Mathematics
Essays
Exams
Sports or catching a ball
Learning the alphabet
Learning times tables
Learning to tell the time
Learning to tie your shoes
Learning to speak or pronounce words
At school, what were you good at?
Did teachers ever comment on your difficulties? Give details:
Please indicate which of these statements apply to you:
Overall, my experience of school was good / YES/NO
I worked hard at school / YES/NO
I missed school for family, medical or other reasons / YES/NO
I attended learning support in school / YES/NO
I attended additional tuition outside of school / YES/NO
I received exam support in my Leaving Certificate examinations? / YES/NO
Section 4: BACKGROUND INFORMATION
Please tick YES or NO
/ YES / NO
Does anybody in your family have difficulty with spelling/ reading/ learning?
Are you right-handed?
Are you left-handed?
Can you use either hand?
Do you have any problems with your eyesight? For example a lazy eye, squint, shortsightedness?
If YES, give details here.
Have you had your eyesight tested?
When you read, does the print seem to move or blur?
Have you had any problems with hearing?
Did you have any ear infections, glue ear or continual sore throats when you were a child?
Have you had any hearing tests?
Do you find it difficult to concentrate when there is background noise?
Were there any problems with your birth?
Did you have problems learning to talk or walk?
Have you suffered from any serious illnesses or accidents?
If YES, give details here.
Do you suffer from migraines or allergies?
Do you take any regular medication that might affect your learning?
If YES, give details here.
Is English your mother tongue?
If not, do you have difficulties with reading and writing in your first language?
Do you speak any other languages?
If yes, did you have any trouble learning them?
Section 5: CURRENT DIFFICULTIES
Do you currently have problems with any of the following?
/
YES
/
NO
Getting information from text books
Remembering what you’ve read
Taking notes from text books
Getting information from lectures/seminars
Taking notes in lectures
Taking exams
Exam revision
Expressing your ideas in writing
Needing to re-write your work often or seem to spend more time on it than others
Organising your written information
Missing out full stops, commas, and other punctuation marks
Writing long rambling sentences
Difficult to read your handwriting
Avoiding words you cannot spell
Making a lot of spelling errors
Missing out words or the endings of words
Finding/correcting your own mistakes
Starting sentences and then forgetting what you were going to put
Meeting deadlines for assignments
Remembering sequences of numbers or letters such as telephone numbers or a car registration
Forgetting people’s names
Learning new words
Section 6: COPING STRATEGIES
What helps to overcome difficulties? Tick YES or NO
/
YES
/
NO
Using a computer, laptop or tablet
Having somebody who can check my work
Using a voice recorder for recording information
Please expand and outline what help you get from others
Section 7: SAMPLE OF YOUR WRITING
We know you probably won’t enjoy this bit, but we do need to see a sample of your writing. Could you summarise your difficulties and say why you are seeking an assessment at this moment in time?
Please spend exactly 5 minutes on this piece of writing and include any information, which you feel may be relevant. Please use the additional sheet if you need to.
Section 7: Writing Sample Continuation Sheet

Thank you for completing this exercise: we know that it can be difficult, but it is necessary to help you.

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