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Academic Problems Parent Student Form

This document is an academic problems questionnaire for parents and students to complete together. It contains 71 questions across various domains including reading, writing, math, organization, attention, and sensory issues. Parents and students are asked to rate how frequently each problem occurs on a scale from 0-4. Space is also provided for additional comments at the end.

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Arnav
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326 views3 pages

Academic Problems Parent Student Form

This document is an academic problems questionnaire for parents and students to complete together. It contains 71 questions across various domains including reading, writing, math, organization, attention, and sensory issues. Parents and students are asked to rate how frequently each problem occurs on a scale from 0-4. Space is also provided for additional comments at the end.

Uploaded by

Arnav
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Student Name:__________________ Parent:_________________________

Academic Problems Questionnaire - Parent/Student Form


The first column is for student responses and the second column is for parent responses. Use your discretion; young
children may not be able to complete or can complete via interview with parent. Please rate the student on each of the
symptoms listed below using the following scale. If there are questions not applicable or not observed, write “NA.”
0 1 2 3 4  NA
Never Rarely Occasionally Frequently Very Frequently Not Applicable/Not Observed

Std Prnt
Reading
___ ___1. I am a poor reader.
___ ___2. I do not like reading.
___ ___3. I make mistakes when reading like skipping words or lines.
___ ___4. I read the same line twice.
___ ___5. I have problems remembering what I read even though I have read all the words.
___ ___6. I reverse letters when I read (such as b/d, p/q).
___ ___7. I switch letters in words when reading (such as god and dog).
___ ___8. I complain that my eyes hurt or water when I read.
___ ___9. Words tend to blur when I read.
___ ___10. Words tend to move around the page when I read.
___ ___11. When reading I have difficulty understanding the main idea or identifying important details
from a story.

Writing
___ ___12. I have “messy “ handwriting.
___ ___13. My work tends to be messy.
___ ___14. I prefer print rather than writing in cursive.
___ ___15. My letters run into each other or there is no space between words.
___ ___16. I have trouble staying within lines.
___ ___17. I have problems with grammar or punctuation.
___ ___18. I am a poor speller.
___ ___19. I have trouble copying off the board or from a page in a book.
___ ___20. I have trouble getting thoughts from my brain to the paper.
___ ___21. I can tell a story but cannot write it.

Body Awareness/ Spatial Relationships


___ ___22. I have trouble with knowing my left from my right.
___ ___23. I have trouble keeping things within columns or coloring within lines.
___ ___24. I tend to be clumsy, uncoordinated.
___ ___25. I have difficulty with eye hand coordination.
___ ___26. I have difficulty with concepts such as up, down, over or under.
___ ___27. I tend to bump into things when walking.

Oral Expressive language


___ ___28. I have difficulty expressing myself in words.
___ ___29. I have trouble finding the right word to say in conversations.
___ ___30. I have trouble talking around a subject or getting to the point in conversations.

Receptive language
___ ___31. I have trouble keeping up or understanding what is being said in conversations.
___ ___32. I tend to misunderstand people and give the wrong answers in conversations.
___ ___33. I have trouble understanding directions people tell me.
___ ___34. I have trouble telling the direction sound is coming from.
___ ___35. I have trouble filtering out background noises.

1
0 1 2 3 4  NA
Never Rarely Occasionally Frequently Very Frequently Not Applicable/Not Observed

Math
___ ___36. I am poor at basic math skills for my age (adding, subtracting, multiplying and dividing)
___ ___37. I makes “careless mistakes” in math.
___ ___38. I tend to switch numbers around.
___ ___39. I have difficulty with word problems.

Sequencing
___ ___40. I have trouble getting everything in the right order when I speak.
___ ___41. I have trouble telling time.
___ ___42. I have trouble using the alphabet in order.
___ ___43. I have trouble saying the months of the year in order.

Abstraction
___ ___44. I have trouble understanding jokes people tell me.
___ ___45. I tend to take things too literally.

Organization
___ ___46. My notebook/paperwork is messy or disorganized.
___ ___47. My room is messy.
___ ___48. I tend to shove everything into my backpack, desk or closet.
___ ___49. I have multiple piles around my room.
___ ___50. I have trouble planning my time.
___ ___51. I am frequently late or in a hurry.
___ ___52. I often do not write down assignments or tasks and end up forgetting what to do.

Memory
___ ___53. I have trouble with my memory.
___ ___54. I remember things from long ago but not recent events.
___ ___55. It is hard for me to memorize things for school or work.
___ ___56. I know something one day but do not remember it to the next.
___ ___57. I forget what I am going to say right in the middle of saying it.
___ ___58. I have trouble following directions that have more than one or two steps.

Social Skills
___ ___59. I have few or no friends.
___ ___60. I have trouble reading body language or facial expressions of others.
___ ___61. My feelings are often or easily hurt.
___ ___62. I tend to get into trouble with friends, teachers, parents or bosses.
___ ___63. I feel uncomfortable around people I do not know well.
___ ___64. I am teased by others.
___ ___65. Friends do not call and ask me to do things with them.
___ ___66. I do not get together with others outside of school or work.

Scotopic Sensitivity
___ ___67. I am light sensitive. Bothered by glare, sunlight, headlights or streetlights.
___ ___68. I become tired, experience headaches, mood changes, feel restless or an inability to stay focused with bright
or fluorescent lights.
___ ___69. I have trouble reading words that are on white, glossy paper.
___ ___70. When reading words or letters shift, shake, blur, move, run together, disappear or become difficult to
perceive.
___ ___71. I feel tense, tired, sleepy, or even get headaches with reading
___ ___72. I have problems judging distance and have difficulty with such things as stairs, ball sports, or driving.

2
0 1 2 3 4  NA
Never Rarely Occasionally Frequently Very Frequently Not Applicable/Not Observed

Sensory Integration Issues


___ ___73. I seem to be more sensitive to the environment than others.
___ ___74. I am more sensitive to noise than others.
___ ___75. I am particularly sensitive to touch or very sensitive to certain clothing or tags on the clothing.
___ ___76. I have unusual sensitivity to certain smells.
___ ___77. I have unusual sensitivity to light.
___ ___78. I am sensitive to movement or crave spinning activities
___ ___79. I tend to be clumsy or accident prone.

Attention, Executive Function, and Hyperactivity


___ ___Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
___ ___Often has difficulty sustaining attention in tasks or play activities
___ ___Often does not seem to listen when spoken to directly
___ ___Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace
(not due to oppositional behavior or failure to understand instructions)
___ ___Often has difficulty organizing tasks and activities
___ ___Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork
or homework)
___ ___Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)
___ ___Is often easily distracted by extraneous stimuli
___ ___Is often forgetful in daily activities
___ ___Often fidgets with hands or feet or squirms in seat
___ ___Often leaves seat in classroom or in other situations in which remaining seated is expected
___ ___Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be
limited to subjective feelings of restlessness)
___ ___Often has difficulty playing or engaging in leisure activities quietly
___ ___Is often "on the go" or often acts as if "driven by a motor"
___ ___Often talks excessively
___ ___Often blurts out answers before questions have been completed
___ ___Often has difficulty waiting turn
___ ___Often interrupts or intrudes on others (e.g., butts into conversations or games)

Thank you for your invaluable input. Please feel free to add any comments below.

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