Before Proceeding To The Questions, Read This Statement Aloud To The Client:

"We are going to ask your questions about your school experiences and your health. Your answers will help us figure out what services you will need to be successfully employed and to help you and your caseworker develop your plan."
"It is very important that you answer these questions so that you can be placed in the right kind of activities and get the help and services you may need to succeed."

SECTION I

1. Have you had any problems learning in middle school or junior high? YESNO

2. Do you have difficulty working from a test booklet to an answer sheet? YESNO

3. Do you have difficulty or experience problems working with numbers in a column? YESNO

4. Do you have trouble judging distances? YESNO

5. Do any family members have learning problems? YESNO

Count the number of "YES" answers for Section I. ________ Multiply by 1 = ________

SECTION II

6. Have you had any problems learning in elementary school? YESNO

7. Do you have difficulty or experience problems mixing mathematical signs (+/x)? YESNO

Count the number of "YES" answers for Section II. ________ Multiply by 2 = ________

SECTION III

8. Do you have difficulty or experience problems filling out forms? YESNO

9. Do you experience difficulty memorizing numbers? YESNO

10. Do you have difficulty remembering how to spell simple words you know? YESNO

Count the number of "YES" answers for Section III. ________ Multiply by 3 = ________

SECTION IV

11. Do you have difficulty or experience problems taking notes? YESNO

12. Do you have trouble adding or subtracting small numbers in your head? YESNO

13. Were you ever in a special program or given extra help in school? YESNO

Count the number of "YES" answers for Section IV. ________ Multiply by 4 = ________

OVERALL TOTAL ____________ If 12 or more, refer for further evaluation