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 SOMETIMES ALWAYS DON’T

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. HANDWRITING SKILLS Never Sometimes Always Don’t know
Can your child hold a pencil/pen with
three finger grasp?
Does your child exhibit poor
handwriting?
Does your child complain of pain while
writing?
Does your child take more time for
writing?
5. 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?
6. 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)?

7. 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?
8. 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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