Adult Questionnaire
Please complete this form as fully as you can as this will help us to help you. The
questionnaire covers your early development, health, and current situation. If it is not
possible to consult your parents or carers about your early development, please
answer as many questions as possible. There are 8 sections on this questionnaire.
Once fully completed, hit the final 'submit' to confirm the status of your questionnaire as
'completed'. Your answers are entirely confidential to the Charity's Staff and other
Professionals directly concerned with you. We are totally committed to protecting your
information and using it responsibly. NB: If you are between 16 and 18 years old and
have not been assessed for dyslexia previously, please could you complete the Family
Questionnaire and the Year 9-13 Student Questionnaire instead of the adult version so
that we can help you as effectively as possible.
First name
Sonia
Last name
Boshor
Salutation
Ms
Known as
Date of birth (DD/MM/YYYY)
16/09/1995
Age
29
Country of Birth
United Kingdom
Date moved to the UK (if applicable)
How do you identify yourself?
Female
Would you like us to contact someone else to arrange the assessment for you?
No
Please provide details of their name
Their relationship to you
Their contact number
Their email address
What are the reasons for having this assessment? Please summarise your
difficulties and concerns with study or at work, and what questions you hope we
can answer.
Not being able to keep a job have very low self esteem struggle with reading and
writing with peers my age. Have problems listening to instructions and understanding
questions and talks a lot.
Do you have any diagnosed Special Educational Need or Disability?
No Special Educational Need identified
Please give further details and upload any reports detailing the identified SEN at
the end of this questionnaire.
I’ve had problems with organisation spelling grammar.
Do you have any concerns about any, as yet unidentified, Special Educational
Need or Disability?
Attention Deficit Hyperactivity Disorder (ADHD)
Have you had a sight test in the last 2 years?
Yes
Is English your first language?
No
If not, have you been speaking English for more than 7 years?
Yes
Health and Developmental History
We would like to understand your health and developmental history, as Specific
Learning Difficulties such as Dyslexia are developmental in nature.
Did you have any early or persisting coordination difficulties?
Yes
If yes, please give more information.
Sometimes listening to instructions and verbal and not understanding left and write
Have you ever been assessed by, or received support from, an occupational
therapist?
No
If yes, please give further information and upload any reports at the end of this
questionnaire.
Are you right or left-handed?
right
Did your speech and language develop well?
No
If no, what was the nature of these difficulties? Please tick one or more of the
following:
expressing language e.g. word-finding
speech difficulties e.g. clarity of speech
Did you receive speech and language therapy?
No
If yes, please give information about any assessments and/or how long the
therapy lasted. Please upload any reports at the end of this questionnaire.
Do any of these difficulties persist?
Yes
If yes, please give more information.
Yes and no I sometimes struggle with coordination and left and right and map reading
Please give information regarding any serious illnesses or medical conditions
that we should be aware of?
Have you had any mental health problems?
Yes
Please give further information if you are happy to.
I’m not diagnosed anxious or anything but I just have times where I do get anxious and
depressed
If you are currently taking any medication which the assessor should be aware
of, please give details here.
No
Do you suffer from any of the following:
Allergies
Hay Fever
Is your hearing within normal limits?
Yes
Have you suffered from ear infections?
Yes
Have you ever had grommets?
No
Please give any additional information about potential hearing loss?
I miss hear things and I have tinnitus sometimes
Vision and Visual Difficulties
In some cases, difficulties with reading are caused by visual difficulties that are not
related to learning. Therefore, we require you to have had a sight test within the last 2
years before proceeding with an assessment. This is a professional standards
requirement. N.B: Prescribed glasses/contact lenses should be worn for an SpLD
assessment unless intended for distance use only. Please answer the following
questions on the Visual Difficulties Screening Protocol. The response categories are:
Always = every day. Often = several times a several times a week but not necessarily
every day. Sometimes = 2-3 times a month. Rarely = only once every few months / a
year.
Have you had any history of visual difficulties / problems with sight / visual
impairment?
No
If yes, please give further information.
When was your last sight test?
09/09/2022
Was any prescription made?
Yes
If yes, were the glasses/contact lenses for:
Distance e.g. watching television
Have you ever used coloured overlays / colour-tinted glasses?
No
If yes, who advised and provided them?
Specsavers
Why were they recommended?
Because I can’t see from distance
Did they help? If yes, in what way?
Yes I can see writing better
Do you still use them? If not, why not?
I forget and it hurts
Approximately how many hours per working/study day do you spend at a screen
(phone, tablet, computer) etc?
10
Approximately how many additional hours per working study day do you spend
reading books, newspapers or other paper-based texts?
0
Has your screen/reading /near work time increased recently? If so, by how
much?
Not sure
If answering always or often to the next 6 questions, we will require you to
please discuss these responses with your optometrist (the person conducting
the sight test) before booking in an assessment.
Oay
Do you get headaches when reading?
Never
Does the print or background shimmer or appear coloured as you read?
Never
Does print appear to jitter or move on the page as you read?
Never
Do you cover or close one eye when reading?
Never
Does text appear blurred, or go in and out of focus, when you read?
Never
Do the words, page or book appear double when you are reading?
Never
Does reading make your eyes feel sore, gritty or watery?
Never
Does reading make you feel tired or sleepy?
Never
Do you become restless, fidgety or distracted when reading?
Often
Do you become less comfortable the longer you read?
Always
Does reading from white paper seem too bright or glaring?
Never
Do parts of the white page between the words form patterns when you read?
Never
Do you rub your eyes to relieve the strain when you are reading?
Never
Do you move your eyes around or blink to keep text clear when you are reading?
Never
Do you use a marker or your finger to stop you losing your place when you
read?
Sometimes
Do you lose your place when reading?
Always
Do you re-read or skip words or lines when reading?
Always
Do objects in the distance appear more blurred after you have been reading?
Never
Familial History of Neurodiversity
Learning is complex, it is helpful to know if other family members have struggled in
these areas. It would be good to check some of this with your parents/carers if you can.
Are there any family members who have Dyslexia, Dyscalculia, DCD - Dyspraxia,
ADHD or Autism Spectrum ?
Yes
If yes, please give further information.
My cousins
Linguistic History
Is English your first language?
No
If no, what is your first language?
Bengali
How long have you been learning and speaking English?
29
Please tell us about any difficulties acquiring speech, language and literacy
skills in your first language?
I forget words and would mix up words
Which language were you educated in?
English
How long have you lived in the UK or other English-speaking country?
No
Educational History
Can you remember having any difficulties learning to read, write and spell,
including handwriting?
Yes
If yes, please give further information.
I would misspell a lot of words and would have trouble reading and understanding
questions
Did you receive additional intervention in the form of learning support and/or
extra tuition either in or outside of school?
Yes
lf yes, please give details of how long and how often the support was received:
e.g. 1 hour per week for 2 years.
1 hour in year 7 and 8 with peers and would have and in juniors
Have you been assessed previously for a specific learning difficulty either by an
Educational Psychologist or a Specialist Teacher Assessor?
No
lf yes, please provide details and upload a copy of your assessment report at the
end of the questionnaire.
Did you have extra time, a reader, a scribe or any other access arrangements in
examinations?
No
lf yes, please note which arrangements and provide details.
Did you have a Statement of Special Educational Needs/Education Health Care
Plan (EHCP)?
No
If yes, please give further information.
Please give details of any disrupted attendance or frequent changes during your
education (school, college or university), if appropriate.
I’ve changed modules so many times
Please give details of any relevant educational attainments and qualifications
The School/College/University, course or qualification and the date.
I have HND and studying BSC
Your Current Situation
What is your current situation?
Employed
Are you currently on a course / studying?
Yes
If yes, please give details (e.g. what and where are you studying, /full-time/part-
time).
Studying part time
Are you currently working?
Yes
If yes, please give the name of your employer, job title and role.
Receptionist and answerpoiny
If you are not employed, what work are you interested in?
What jobs have you had in the past?
I’ve been an analyst sales analyst credit controller financial tech
Your Experiences and Concerns
Do you have any difficulties with reading accurately?
Yes
Do you have any difficulties with reading at an appropriate and fluent speed?
Yes
Do you have any difficulties with understanding what you read?
Yes
Do you have any difficulties with interpreting exam questions and/or written
instructions?
Yes
Do you have any difficulties with remembering what you have read?
Yes
Do you have any difficulties with reading lengthy passages of text?
Yes
Do you have any difficulties with spelling?
Yes
Do you have any difficulties with handwriting legibility?
No
Do you have any difficulties with handwriting speed?
Yes
Do you have any difficulties with producing and organising written essays,
reports, assignments, documents?
Yes
Do you have any difficulties with proofreading?
Yes
Do you have any difficulties with writing notes when someone is talking?
Yes
Do you have any difficulties with copying from a screen, board or book?
Yes
Do you have any difficulties with organising your time?
Yes
Do you have any difficulties with prioritising tasks?
Yes
Do you have any difficulties with estimating how long a piece of work is going to
take?
Yes
Do you have any difficulties with meeting deadlines?
Yes
Do you have any difficulties with finishing exams in time?
No
Do you have any difficulties with retaining new instructions and information?
Yes
Do you have any difficulties with following written and/or spoken instructions?
Yes
Do you have any difficulties with memory?
Yes
Do you have any difficulties with learning information?
Yes
Do you have any difficulties with maintaining concentration and attention?
Yes
Do you have any difficulties with social interaction, communication, maintenance
of eye-contact?
Yes
Do you have any difficulties with delivering presentations or speaking in public?
No
Do you have any difficulties with word finding, pronouncing words?
Yes
Do you have any difficulties with mathematical components of study/work?
No
Please give details of any other challenges that might be relevant, e.g. spatial
orientation, left-right confusion, map reading or driving.
Spatial left and right confusion
If any of the above difficulties listed affect either your work, training or education
(past or present), please give further information.
Training and even with managing multiple tasks
If there is any information that you would like the assessor to know but do not
want to be included in the assessment report, please indicate it here.
On the waiting list for adhd
Please provide information about your strengths, including your hobbies and
special interests.
I don’t have much hobbies other than playing games
Please add any other information not covered within this questionnaire that you
would like us to know.
Thank you for completing the questionnaire. Please click ‘submit’ to confirm
completion. Any additional reports can be securely uploaded via the link
provided in your notification requesting background information. Thank you.
