| 1. My child has difficulty concentrating and paying attention. | |||
| 1.never | 2.sometimes | 3.often | |
| 2. My child requires a lot of time to complete homework. | |||
| 1.never | 2.sometimes | 3.often | |
| 3. My child complains of blurred vision, or double vision when reading. | |||
| 1.never | 2.sometimes | 3.often | |
| 4. My child complains of eyestrain or headaches when reading. | |||
| 1.never | 2.sometimes | 3.often | |
| 5. My child loses his/her place when reading or skips words or lines. | |||
| 1.never | 2.sometimes | 3.often | |
| 6. My child has difficulty copying from the board. | |||
| 1.never | 2.sometimes | 3.often | |
| 7. My child has difficulty with handwriting. | |||
| 1.never | 2.sometimes | 3.often | |
| 8. My child reverses letters, numbers or confuses similar words. | |||
| 1.never | 2.sometimes | 3.often | |
| 9. My child becomes tired or sleepy after short periods of time or his/her reading comprehension deteriorates with time. | |||
| 1.never | 2.sometimes | 3.often | |
| 10. My child has struggled in school. | |||
| 1.never | 2.sometimes | 3.often |