SECTION A

1. Did you have any problems learning in middle/junior high school?
   • YES
   • NO
2. Do any family members have learning problems?
   • YES
   • NO
3. Do you have difficulty working with numbers in columns?
   • YES
   • NO
4. Do you have trouble judging distances?
   • YES
   • NO
5. Do you have problems working from a test booklet to an answer sheet?
   • YES
   • NO

Count the number of "Yeses" for Section A × 1 =

SECTION B

6. Do you have difficulty or experience problems mixing arithmetic sign (+/×)?
   • YES
   • NO
7. Did you have any problems learning in elementary school?
   • YES
   • NO

Count the number of "Yeses" for Section B × 2 =

SECTION C

8. Do you have difficulty remembering how to spell simple words you know?
   • YES
   • NO
9. Do you have difficulty filling out forms?
   • YES
   • NO
10. Did you (do you) experience difficulty memorizing numbers?
    • YES
    • NO

Count the number of "Yeses" for Section C × 3 =

SECTION D

11. Do you have trouble adding and subtracting small numbers in your head?
    • YES
    • NO
12. Do you have difficulty or experience problems taking notes?
    • YES
    • NO
13. Were you ever in a special program or given extra help in school?
    • YES
    • NO

Count the number of "Yeses" for Section D × 4 =

TOTAL YESES MULTIPLIED BY FACTOR INDICATED
FOR SECTIONS A, B, C, D