Problem Checklist Problem Checklist Codename * Date of Birth Date Check the appropriate responses whether they describe you at home, school or work. A little/Rarely Often/Very Often 1. I am a good speaker, but when I read, the words and letters seem to jump around on the page A little/Rarely Often/Very Often 2. I lose my place easily when I am reading A little/Rarely Often/Very Often 3. I have trouble pronouncing long words A little/Rarely Often/Very Often 4. I have trouble sounding out new words A little/Rarely Often/Very Often 5. I understand a story better if someone reads it to me A little/Rarely Often/Very Often 6. I usually remember verbal instructions, but have to read things several times before I understand them A little/Rarely Often/Very Often 7. I remember things I hear, but misspell small words as often as big words A little/Rarely Often/Very Often 8. I can spell the same word several ways in the same story A little/Rarely Often/Very Often 9. I remember faces but have trouble remembering people’s A little/Rarely Often/Very Often 10. I can sound out words, but I don’t remember what words look like A little/Rarely Often/Very Often 11. I sometimes reverse letters or numbers, or get them in the wrong order A little/Rarely Often/Very Often 12. It takes me a while to find my way around a new place A little/Rarely Often/Very Often 13. I have trouble judging distances A little/Rarely Often/Very Often 14. I confuse left and right A little/Rarely Often/Very Often 15. Driving is something I have always avoided A little/Rarely Often/Very Often 16. I have excellent reading abilities, but trouble remembering multiplication tables A little/Rarely Often/Very Often 17. I can’t figure out what formulas to use in math questions A little/Rarely Often/Very Often 18. I know what to do in math questions, but I get the calculations wrong if I don’t use a calculator A little/Rarely Often/Very Often 19. I write well, but have trouble figuring out what they’re asking in math word problems A little/Rarely Often/Very Often 20. I make mistakes when working through math problems that have several steps A little/Rarely Often/Very Often 21. I lose my place when copying from the blackboard or an overhead A little/Rarely Often/Very Often 22. I organize my spoken conversation well, but my handwriting is hard for other people to read A little/Rarely Often/Very Often 23. I have trouble finding things on a cluttered desk A little/Rarely Often/Very Often 24. Jigsaw puzzles are something I’ve always avoided A little/Rarely Often/Very Often 25. I have trouble finding the right place to fill in information on forms A little/Rarely Often/Very Often 26. I respond well to written instruction, but have trouble understanding what people are saying to me, especially when they speak quickly A little/Rarely Often/Very Often 27. If a job is broken up into small chunks, I perform better. A little/Rarely Often/Very Often 28. I have trouble thinking of the right word to say or write, even when I know the word A little/Rarely Often/Very Often 29. I write well but get confused when I’m trying to explain things to people. A little/Rarely Often/Very Often 30. I express myself better when speaking than when writing A little/Rarely Often/Very Often 31. I have lots of good ideas in meetings, but other people don’t understand what I am trying to say in my writing A little/Rarely Often/Very Often 32. I learn best when someone shows me what to do A little/Rarely Often/Very Often 33. I have trouble getting my ideas down on paper A little/Rarely Often/Very Often 34. I get confused when I’m trying to do too many things at once A little/Rarely Often/Very Often 35. It takes me a while to figure things out A little/Rarely Often/Very Often 36. I have trouble judging how much time tasks are going to take to complete A little/Rarely Often/Very Often 37. I am often late getting places A little/Rarely Often/Very Often 38. I don't finish writing tests within the given time A little/Rarely Often/Very Often 39. I get along with people, but I sit by myself at lunch A little/Rarely Often/Very Often 40. I love social gatherings, but tend to interrupt discussions A little/Rarely Often/Very Often 41. I zone out, my mind wanders, or I get distracted by my own thoughts A little/Rarely Often/Very Often 42. It’s hard to stay focused on tasks (studying, homework), and even fun things (TV) A little/Rarely Often/Very Often 43. I fidget with my hands/feet, squirm, or find it hard to sit still A little/Rarely Often/Very Often 44. People have told me that I talk a lot A little/Rarely Often/Very Often 45. It’s hard for me to start or switch tasks once I’ve started A little/Rarely Often/Very Often 46. I have difficulty remembering the order that must be followed when I am given instructions A little/Rarely Often/Very Often If you are human, leave this field blank. Submit Δ
