I confirm I have completed test 1A & 2A on my own without any form of assistance.

Signature*

Date*

SECTION YES OR NO
1. Have you had any problems learning in middle school or junior high?Yes No*
2. Do you have difficulty working from a test booklet to an answer sheet?Yes No*
3. Do you have difficulty or experience problems working with numbers in a column?Yes No*
4. Do you have trouble judging distances?Yes No*
5. Do any family members have learning problems? Yes No*
6. Have you had any problems learning in elementary school? Yes No*
7. Do you have difficulty or experience problems mixing mathematical signs (+/x)? Yes No*
8. Do you have difficulty or experience problems filling out forms? Yes No*
9. Do you experience problems or difficulty memorizing numbers? Yes No*
10. Do you have difficulty remembering how to spell simple words you know? Yes No*
11. Do you have difficulty or experience problems taking notes? Yes No*
12. Do you have trouble adding or subtracting small numbers in your head? Yes No*
13. Were you ever in a special program or given extra help in school? Yes No*

EDUCATION
14. Were you ever in special education classes in school? Yes No*
15. Have you ever been diagnosed or told you have Learning Disabilities? Yes No*
If YES, by Whom When? Type(s) of Learning Disability (if known):

16. Have you ever been diagnosed or told you have Learning Disabilities with or without hyperactivity?
Yes No*

GLASSES
17. Do you need or wear glasses or contact lenses? Yes No*
18. Was your last vision test within the last two years? Yes No*

HEARING
19. Do you need or wear a hearing aid? Yes No*
20. Have you had your hearing tested in the last 12 months? Yes No*

SPEECH
21. Have you ever seen a speech or language therapist? Yes No*

MEDICAL/PHYSICAL
21. Have you ever had any of the following:
• a lot of ear infections? Yes No*
• a lot of sinus problems? Yes No*
• high fevers that lasted a long time? Yes No*
• diabetes (high blood sugar)? Yes No*
• severe allergies? Yes No*
• a lot of headaches or migraines? Yes No*
• a head injury? Yes No*
• convulsions or seizures? Yes No*
• serious health problems? Yes No*

23. Are you taking any medication that affect the way you think, act, or feel? Yes No*
If YES, What?

Signature: Signature* Date: Date*

Please check below:
Signed by Participant Signed by Parent/Guardian of Participant (If Participant Is under 18 years of age)*