Home-Based Assessment

Parents’ Names ________________________________Child’s Name __________________

Phone Numbers _______________________________ Child’s Birth date _______________

E-mail address _______________________________ School grade (this year) _________

Since 1997, we have been helping students to succeed. The 3 most common challenges we have found are:

- Most smart struggling kids learn best when they see and experience information -- we call them

right-brained learners and they are often bright right-brained learners.

- Over 70% of these students have a visual processing challenge.

- Over 70% of these students have an attention issue to that which is boring or frustrating.

This assessment is designed to help you understand which of these three factors are impacting your child. Once you know this, you will be better positioned to help your child.

Complete the assessment and fax it to us at 561-361-7497 or better yet email it to us at: success@3dlearner.com - Subject: 3D Learner Home-based Assessment

Most pressing problem/concern___________________________________________________________

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Complete the following statements about your child- include school and non-school activities.

My child is good at _____________________________________________________________________

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My child has difficulty with_______________________________________________________________

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Visual Screening Tool

Parent Instructions: read the following Subject Instructions to your child and then each item exactly as written.

If subject responds with “yes” – please qualify with frequency choices. Do not give examples.

Subject Instructions: Please answer the following questions about how your eyes feel when reading or doing close work.

		Never	(Not very often) Infrequently	Sometimes	Fairly Often	Always
1.	Do your eyes feel tired when reading or doing close work?
2.	Do your eyes feel uncomfortable when reading or doing close work?
3.	Do you have headaches when reading or doing close work?
4.	Do you feel sleepy when reading or doing close work?
5.	Do you lose concentration when reading or doing close work?
6.	Do you have trouble remembering what you have read?
7.	Do you have double vision when reading or doing close work?
8.	Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
9.	Do you feel like you read slowly?
10.	Do your eyes ever hurt when reading or doing close work?
11.	Do your eyes ever feel sore when reading or doing close work?
12.	Do you feel a “puffing” feeling around your eyes when reading or doing close work?
13.	Do you notice the words blurring or coming in and out of focus when reading or doing close work?
14.	Do you lose your place when reading or doing close work?
15.	Do you have to re-read the same line of words when reading?

Convergence Insufficiency Symptom Survey---V15 from Borsting EJ, Rouse MW, Mitchell GL, Cotter SA et al. (2003) Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9 to 18 years. Optom Vis Sci 80:832=-838.

Comments _______________________________________________________________________________________
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Is Your Child Inattentive?

Parent Instructions: Answer the following statements about your child. If Yes, please qualify with frequency choices.

Does your child:

		Never	(Not very often) Infrequently	Sometimes	Fairly Often	Always
1.	Have difficulty paying close attention to details?
2.	Make careless mistakes in schoolwork, work, or other activities?
3.	Have difficulty keeping (sustaining) attention on tasks or play activities?
4.	Not seem to listen when spoken to directly?
5.	Not follow through with instructions? (not due to oppositional behavior or failure to understand instructions).
6.	Fail to finish schoolwork, chores or duties?
7.	Not hand in assignments, even when completed?
8.	Have trouble organizing activities?
9.	Avoid, dislike, or not want to do things that take a lot of mental effort for a long period of time? (such as schoolwork or homework).
10.	Do you lose things needed for tasks and activities? (e.g. toys, school assignments, pencils, books, or tools).
11.	Get distracted?
12.	Forget daily activities?
13.	Interrupt other people's conversations

Comments _______________________________________________________________________________________
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Is Your Child a Right-Brained Learner

(Check the correct answer)

Does your child

1	Think mainly in pictures instead of words?	Yes	_____	No	_____
2	Know many things without being able to explain how and why?	Yes	_____	No	_____
3	Solve problems in unusual ways?	Yes	_____	No	_____
4	Have a vivid imagination?	Yes	_____	No	_____
5	Remember what they have seen and forget what they have heard?	Yes	_____	No	_____
6	Struggle with spelling? (Even if they did well on spelling tests)	Yes	_____	No	_____
7	Visualize objects from different perspective?	Yes	_____	No	_____
8	Struggle with organization?	Yes	_____	No	_____
9	Often lose track of time?	Yes	_____	No	_____
10	Prefer to read a map rather than following verbal directions?	Yes	_____	No	_____
11	Often remember how to get to places they only visited once?	Yes	_____	No	_____
12	Have handwriting that is difficult for others to read?	Yes	_____	No	_____
13	Feel what others are feeling?	Yes	_____	No	_____
14	Have musical, artistic or mechanical skills?	Yes	_____	No	_____
15	Know more than others give them credit for?	Yes	_____	No	_____
16	Hate speaking in front of groups?	Yes	_____	No	_____
17	Feel smarter as they get older?	Yes	_____	No	_____
18	Get addicted to computers?	Yes	_____	No	_____

Source: Dr. Linda Silverman, author of "Upside-Down Brilliance", adapted from Visual-Spatial Identifier.