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1. Is there a family history of learning disabilities? * YesNoI don't know

2. Do you have difficulty sounding out words phonetically, particularly new words like proper names, technical or industry terms? For example, "Telephony" as "tə/le/fə/nē" ?* YesNoI don't know

3. Do you find yourself incorrectly copying or transferring notes from a white board, screen or paper, by missing information, misspelling, or reversing information?* YesNoI don't know

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4. Compared to your peers at school or work, do you feel your reading ability or speed seems worse than that of people you view as your intellectual peers? * YesNoI don't know

5. Compared to your peers at school or work, do you feel that your performance in testing situations does not accurately reflect your intelligence or knowledge? * YesNoI don't know

6. Compared to your peers at school or work, are you less comfortable reading from a book, script, or notes out loud? * YesNoI don't know

7. Do you prefer to receive information through means other than reading, such as by using video, audio, brief notes or summaries, or conversation? * YesNoI don't know

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8. Do you struggle with solving mathematical word problems in school or at work compared to your ability to execute calculations or understand mathematical operations? * YesNoI don't know

9. Do you struggle with taking multiple choice tests due to misunderstanding or misreading details in the question, rather than lack of knowledge about the answer? * YesNoI don't know

10. Do you require more time than others to write thoughts down with appropriate grammar, punctuation or phrasing? * YesNoI don't know

11. As a child or an adult, did or do you make reading mistakes in letters, numbers, or grammar, such as confusing "a " and "o " (pat, pot); "7" and"1"; or not seeing punctuation such as periods and commas? * YesNoI don't know

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12. Have you been told that, as a child, you had trouble learning left and right or processing spatial directions ("Find the toy underneath the bed")? * YesNoI don't know

13. Do you struggle or need significantly more time than others to understand multi-step processes or directions (written or oral), as in following written instructions? * YesNoI don't know

14. When speaking, do you confuse homonyms (words that sound like one another but have different meanings), have difficulty accurately expressing words or phrases, or mispronounce common names and items more frequently than others? * YesNoI don't know

15. Are your fine or gross motor skills (handwriting, catching or throwing a ball, team sports) considerably weaker than your peers? * YesNoI don't know

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