College & Beyond
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Gross and Fine Motor Skills

How accurate is each of the following statements about your child?

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Extremely
accurate

1. Appears awkward and clumsy, dropping, spilling, or knocking things over.

2. Has trouble with buttons, hooks, snaps, zippers, and learning to tie shoes.

3. Creates art work that is immature for age.

4. Demonstrates poor ability to color or write 'within the lines'.

5. Grasps pencil awkwardly, resulting in poor handwriting.

6. Experiences difficulty using small objects or items that demand precision
    (e.g., Legos, puzzle pieces, tweezers, scissors).

7. Dislikes and avoids writing / drawing tasks.

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accurate

Learning

How accurate is each of the following statements about your child?

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accurate

1. Demonstrates early delays in learning to speak.

2. Has difficulty modulating voice (e.g., too soft, too loud).

3. Has trouble naming people or objects.

4. Has difficulty staying on topic.

5. Inserts invented words into conversation.

6. Has difficulty re-telling what has just been said.

7. Uses vague, imprecise language and has a limited vocabulary.

8. Demonstrates slow and halting speech, using lots of fillers
    (e.g., uh, um, and, you know, so).

9. Mispronounces words frequently.

10. Has difficulty rhyming.

11. Has limited interest in books or stories.

12. Has difficulty understanding instructions or directions.

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Reading

How accurate is each of the following statements about your child?

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accurate

1. Confuses similar-looking letters and numbers.

2. Demonstrates poor memory for printed words.

3. Has trouble naming letters.

4. Has problems associating letter and sounds, understanding the difference
    between sounds in words or blending sounds into words.

5. Has poor retention of new vocabulary.

6. Dislikes and avoids reading or reads reluctantly.

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Written Language

How accurate is each of the following statements about your child?

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accurate

1. Dislikes and avoids writing and copying.

2. Demonstrates delays in learning to copy and write.

3. Has difficulty remembering shapes of letters and numerals.

4. Frequently reverses letters, numbers, and symbols.

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Attention

How accurate is each of the following statements about your child?

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accurate

1. Fails to pay close attention to details or makes careless mistakes
    in schoolwork, work, or other activities.

2. Has difficulty sustaining attention in work tasks or play activities.

3. Does not follow through on instructions and fails to finish
    schoolwork, chores, or duties in the workplace.

4. Has difficulty organizing tasks and activities.

5. Avoids, dislikes, or is reluctant to engage in tasks that require
    sustained mental effort such as homework and organizing work tasks.

6. Loses things consistently that are necessary for tasks / activities
    (e.g., toys, school assignments, pencils, books, or tools).

7. Is easily distracted by outside influences.

8. Is forgetful in daily/routine activities.

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accurate

Math

How accurate is each of the following statements about your child?

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accurate

1. Has difficulty with simple counting and one-to-one correspondence between
    number symbols and items / objects.

2. Has trouble telling time.

3. Has trouble conceptualizing passage of time.

4. Has difficulty counting rapidly or making calculations.

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accurate

Social/Emotional

How accurate is each of the following statements about your child?

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Extremely
accurate

1. Has difficulty 'joining in' and maintaining positive social status
    in a peer group.

2. Has difficulty with self-control when frustrated.

About You

Full Name:

Email Address:*

Phone Number:

Preferred Contact Method: Phone Email

What is your role?* -- Please select -- Parent Teacher Professional Relative Adult

What is the grade level of the person you're describing?* -- Please select -- PreK - 2nd Grade 3rd Grade - 8th Grade 9th Grade - 12th Grade College - Adult

What are your areas of concern?* Gross and Fine Motor Skills
Language
Reading
Written Language
Attention
Math
Social/Emotional
Other

Our Learning Disabilities Checklist is designed as a helpful guide and not as a tool to pinpoint specific learning disabilities. Many disorders of language, learning, attention and behavior share common characteristics, and the LD Checklist is not intended to rule in or rule out one type of disorder or another. This tool is intended only to increase awareness of behaviors that point to risk for LD , and not as a substitute for a comprehensive evaluation by trained professionals.
I understand

**Checklist provided by National Center for Learning Disabilties.
Dr. Duane is a standing member of the Board of Directors of the NCLD.

There are seven major areas of brain skills that make it possible to think, learn, read, pay attention, and remember. Any skills with scores in the higher percentile indicate a potential weakness that may be making life far more difficult than it needs to be.

http://kidshealth.org/kid/health_problems/learning_problem/dyslexia.html
http://dyslexiahelp.umich.edu/
http://www.eyetoeyenational.org/

(Goldman, Larry S., et al. "Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents." JAMA: the journal of the American Medical Association 279.14 (1998): 1100-1107.)
(Elia, Josephine, Paul J. Ambrosini, and Judith L. Rapoport. "Treatment of attention-deficit–hyperactivity disorder." New England Journal of Medicine340.10 (1999): 780-788.)
(Wolraich, Mark L., et al. "Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications." Pediatrics 115.6 (2005): 1734-1746.)
American Academy of Child and Adolescent Psychiatry (brochure)

"Diagnosing Obsessive-Compulsive Disorder (OCD)." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 03 July 2013. Web. 04 Nov. 2013.
"Obsessive-compulsive Disorder." NCBI. U.S. National Library of Medicine, 26 Feb. 2013. Web. 04 Nov. 2013.

"Autism Spectrum Disorder." National Institute of Mental Health. Web. 04 Nov. 2013. http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml
"What Is Autism?" Autism Speaks. Web. 04 Nov. 2013. http://www.autismspeaks.org/

http://www.mayoclinic.com/health/oppositional-defiant-disorder/DS00630\
http://www.webmd.com/mental-health/oppositional-defiant-disorder?page=2
Hamilton, S. S., & Armando, J. (2008). Oppositional defiant disorder. American Family Physician, 78(7), 861