Dyslexia Screening Booklet

The Dyslexia Screening Booklet is a referral document that needs to be completed by

both the teacher and parents. It is designed for teachers and parents to provide key
information to assist them in identifying primary school children who exhibit specific
literacy difficulties or dyslexia.

CONTENTS OF BOOKLET

Background Information p2
Teacher’s Checklist p 3-5
Parent’s Checklist p 6-8

USING THE BOOKLET

1. Complete all sections

2. Ensure parents are given the Parent’s Checklist to complete
3. Attach recent samples of pupil’s school work

Dyslexia Screening Booklet: 1

 BACKGROUND INFORMATION
To be completed by school personnel

Name of Child:

DOB: BC:

Gender: * Male / Female Race:

School:

Class: Session: * AM / PM

Home Address:

Parent’s Name :

Parent’s Contact Nos: (Home) (Off) (Hp)

Father’s Occupation:

Mother’s Occupation:

Kindergarten name: No of years :

Outside Agency / External Professional Involvement :

School Performance Record:

English Math Mother Tongue

SA1 SA2 SA1 SA2 SA1 SA2
P1
P2
P3
P4
P5
P6

Parental Consent Obtained : YES / NO

Person making Referral : Date:

Relation to Child:
Dyslexia Screening Booklet: 2
 TEACHER’S CHECKLIST

Please indicate to your best knowledge if the child shows significant difficulties in the
following areas. Where necessary, teacher should carry out observations in order to
provide more accurate information.

Please be reminded that samples of the child’s work should be included.

YES NO
READING
1. Reads very slowly
2. Reads hesitantly
3. Constantly loses place, e.g. misses out whole chunks of passage or
repeating paragraphs
4. Difficulty tracking words along a line of print
5. Frequently skips or re-reads a line of words
6. Difficulty recognising familiar words, e.g. there, his, with, want
7. Confuses similar looking words, e.g. on/no, was/saw
8. Misreads initial consonants, e.g. might for night
9. Guesses wildly at words
10. Substitutes words of similar meaning, e.g. jungle for forest
11. Disregards punctuation, e.g. reads without appropriate pauses
12. Misreads words by changing the position of letters within the
word, e.g. tired for tried; bread for beard
13. Misreads syllables, e.g. hospital for hospital

14. Difficulty comprehending a passage even if correctly read

PHONOLOGY
1. Difficulty identifying words with the same beginning sound, e.g.
fat and fox; tin and top
2. Difficulty identifying rhyming words, e.g. Jill and hill, mop and
top
SPELLING/ WRITING
1. Poor standard of written work, i.e. written work is usually full of
spelling and grammatical errors
2. Standard of written work not equal to ability in oral language, i.e.
child speaks better than he/she writes
3. Messy and poorly organised work, often full of corrections and
Dyslexia Screening Booklet: 3
 YES NO
erasure marks
4. Poorly organized work, characterised by irregular spacing
between words
5. Poor penmanship, e.g. letters written in different sizes, letters
hardly written on the line
6. Bizarre spelling, e.g. ‘pokegt’ for ‘pocket’; ‘Fedury’ for
‘February’
7. Confusion of letters that look similar, e.g. h/n/r, m/n/w
8. Mirror-writing of letters and numbers, e.g. b/d, p/q, 6/
9. Foreshortening of words, e.g. ‘rember’ for ‘remember’, ‘sudly’
for ‘suddenly’
10. Wrong order of letters in words, e.g. ‘hlep' for ‘help’, ‘brid’ for
‘bird’
11. Indiscriminate use of capitals, e.g. John haS A peN
12. Difficulty writing the alphabet in sequence
13. Difficulty copying accurately from the whiteboard
14. Difficulty writing letters even when they are dictated in name
MOTOR SKILLS
1. Appears clumsy
2. Difficulty catching or throwing a ball
3. Difficulty hopping or skipping
SPEECH, CONCEPTS AND MEMORY
1. Difficulty finding the right words for things (e.g. persistent word
searching)
2. Persistently jumbles phrases
3. Difficulty distinguishing left and right
4. Difficulty telling time
5. Difficulty remembering days of the week
6. Difficulty remembering own birthday, telephone number, address
7. Difficulty with the concepts of yesterday and tomorrow
8. Difficulty following a sequence of verbal instructions

Dyslexia Screening Booklet: 4

BEHAVIOUR
1. Shows difficulty displaying attentive behaviour (e.g. looking at
teacher, listening to teacher) when teacher is instructing
2. Shows difficulty completing tasks on time
3. Easily distracted by sounds
4. Easily distracted by actions of others
5. Easily distracted by bright lights
6. Easily frustrated (e.g. becomes angry quickly)
7. Easily reduced to tears
8. Lacks interest/motivation in academic tasks
9. Lacks continuity of effort and perseverance
10. Does not stay in his seat
11. Does not bring materials needed for lessons
12. Interrupts the teacher during lessons
12. Constantly seeks attention, approval and/or praise
13. Constantly fidgets and is restless
14. Passive in class, rarely initiating conversation or responding in
class, unless called upon
15. Withdrawn in class, deliberately avoiding interaction with
teacher/peers
17. Fights/quarrels with peers
PHYSIOLOGY
1. Does the child have problems with eyesight?
2. Does the child have problems with hearing?

Dyslexia Screening Booklet: 5

Child’s strengths :

Child’s main difficulties in school:

Support provided for child in class / school:

Strategies that have worked effectively with child:

Language most frequently used by the child with his peers in school:

Additional Information -

Teacher : ______________________________ Date: _________________

Teacher’s teaching subjects :

Dyslexia Screening Booklet: 6
 PARENT’S CHECKLIST
Detach this portion for parents

NAME OF CHILD:
Date of Birth :
Class :

Dear parent(s),

This is to assist us in gaining a better understanding of your child’s learning difficulties.

Please indicate to your best knowledge if your child shows significant difficulties in the
following areas. It may be necessary to carry out some observations in order to provide
more accurate responses.

YES NO
READING
1. Reads slowly
2. Reads hesitantly
3. Constantly loses place, e.g. misses out whole chunks of passage or
repeating paragraphs
4. Difficulty tracking words along a line of print
5. Frequently skips or re-reads a line of words
6. Difficulty recognising familiar words
7. Confuses similar looking words, e.g. on/no, was/saw
8. Misreads initial consonants, e.g. might for night
9. Guesses wildly at words
10. Substitutes words of similar meaning, e.g. jungle for forest
11. Disregards punctuation, e.g. reads without appropriate pauses
12. Misreads words by changing the position of letters within the
word, e.g. tired for tried; bread for beard
13. Misreads syllables, e.g. hopsital for hospital
14. Difficulty comprehending a passage even if correctly read
PHONOLOGY
1. Difficulty identifying words with the same beginning sound, e.g.
fat and fox; tin and top
2. Difficulty identifying rhyming words, e.g. Jill and hill, mop and
top

Dyslexia Screening Booklet: 7

SPELLING/ WRITING
1. Poor standard of written work, i.e. written work is usually full of
spelling and grammatical errors
3. Standard of written work not equal to ability in oral language, i.e.
child speaks better than he/she writes
3. Messy work, often full of corrections and erasure marks
4. Poorly organized work, characterized by irregular spacing
between words
5. Poor penmanship, e.g. letters written in different sizes, letters
hardly written on the line
6. Bizarre spelling, e.g. ‘pokegt’ for ‘pocket’; ‘Fedury’ for
‘February’
7. Confusion of letters that look similar, e.g. h/n/r, m/n/w
8. Mirror-writing of letters and numbers, e.g. b/d, p/q, 6/
9. Foreshortening of words, e.g. ‘rember’ for ‘remember’, ‘sudly’
for ‘suddenly’
10. Wrong order of letters in words, e.g. ‘hlep' for ‘help’, ‘brid’ for
‘bird’
11. Indiscriminate use of capitals, e.g. John haS A peN
12. Difficulty writing the alphabet in sequence
13. Difficulty writing letters even when they are dictated in name
MOTOR SKILLS
1. Appears clumsy
2. Difficulty catching or throwing a ball
3. Difficulty hopping or skipping
4. Difficulty fastening shoelaces
SPEECH, CONCEPTS AND MEMORY
1. Difficulty finding the right words for things (e.g. persistent word
searching)
2. Persistently jumbles phrases
3. Difficulty distinguishing left and right
4. Difficulty telling time
5. Difficulty remembering days of the week
6. Difficulty remembering own birthday, telephone number, address
7. Difficulty with the concepts of yesterday and tomorrow

Dyslexia Screening Booklet: 8

8. Difficulty following a sequence of verbal instructions

BEHAVIOUR
1. Shows difficulty displaying attentive behaviour (e.g. looking at
and/or listening to the person speaking)
2. Shows difficulty completing tasks on time
3. Easily distracted
4. Easily frustrated (e.g. becomes angry easily)
5. Easily reduced to tears
6. Lacks motivation/interest in academic tasks
7. Lacks continuity of effort and perseverance
8. Constantly seeks attention, approval and/or praise
9. Passive, rarely initiating conversation at home
10. Withdrawn, deliberately avoiding interaction with family
members
PHYSIOLOGY
1. Delayed speech milestones, i.e. developing speech later than the
age of 2
2. Delayed motor milestones, i.e. starting to walk later than the age
of 2½ years
3. Late in deciding which hand to use
4. Any eyesight problems?
5. Any hearing problems?
6. Any family history of reading difficulties?

Dyslexia Screening Booklet: 9

Child’s strengths:

Child’s main difficulties:

Medical history (e.g. accidents, illness, hospitalisation):

Details:

Outside agency or professional involvement (e.g., psychiatrist, occupational therapist,

speech & language therapist, psychologist, learning centre/tuition, etc):

Details:

Most frequently spoken language(s) at home -

Additional Information –

Name & Signature of Parent:

Date: _________________

Dyslexia Screening Booklet: 10