1. Do you have, or have you had in the past problems with any of the following?:
     Yes No  Yes No
    Hearing      X    Allergies      X   
    Vision X         Drug Abuse      X   
    Head Injury      X    Alcohol Abuse      X   
    Emotional Trauma      X    Ear Infections X        
    Headaches      X    Migraines      X   
    If yes, please describe: glasses since Grade 8 and childhood ear infections
  2. Have you had a history of depression, anxiety or other emotional or psychological difficulties (for example: Obsessive Compulsive Disorder, school phobia, suicide attempts)?
     
    Yes  graphic of checkbox  No  graphic of X
  3. Have you ever taken medication for this condition?
     
    Yes  graphic of checkbox  No  graphic of X
    If yes, please give details:


Indicators of a POSSIBLE learning disability:
  • If the learner reports that letters and words appear out of sequence or reversed, these could be signs of a learning disability and should be investigated further.
  • If the learner appears to be able to hear but has difficulty discriminating similar sounding words or saying words correctly (this does not apply to an English-as-a-Second-Language student), these problems should also be investigated further as signs of a learning disability. These problems often occur more frequently when there is a history of ear infections.
  • If the learner's hearing appears normal, but the student frequently misunderstands questions, there may be a learning disability - a language processing problem.
  • If the student frequently asks to have questions repeated, there could be learning disabilities related to attention and/or auditory processing.

Not likely indicators of a learning disability:
  • If the learner frequently has problems in situations requiring listening skills, the possibility of a hearing problem should be ruled out by a hearing test with an audiologist.
  • If the learner is taking any medication regularly, you should investigate the possible side effects of the medication and how it may impact on learning (fatigue, memory, attention...)
  • Learners with ongoing problems with anxiety or depression may have difficulty coping with academic learning situations, especially the testing process.
  • If the learner experiences eye strain when reading or copying notes from a distance, the possibility of vision difficulties should be further explored.