Calendar
Directions
Contact
Services
Physician Information
 
 
 
 
 
 
 
 

PATIENT/STUDENT QUESTIONNAIRE

Download Printable PDF Form

Dear Student,
Please fill out this form to help me understand your learning style and skills. I look forward to meeting you soon.

Thank you very much.
Your Name
Age
Your School
Grade
Your Teacher’s Name
What do you enjoy doing in your free time?
Hobbies
Sports
Entertainment
Family Activities
Other
Compared to other people your age, how well do you do at your hobbies and sports?
  Not As Well As Others About The Same As Others Better Than Most
Hobbies
Sports
Do you have any brothers and sisters? What are their names and ages?
Who are your friends? Please tell me their names and ages.
Who are your friends? Please tell me their names and ages.
  Not As Well As Others About The Same As Others Better Than Most
Your Brothers/Sisters
Your Friends/Classmates
Your Parents
Your Teachers
What chores do you have at home?
Do you have any paid chores or jobs (paper route, regular job, etc.?
Do you have any physical illness or handicap?
What would you like to do when you become an adult?
Please name two or three things you enjoy about school.
What is your best subject? Why do you like it?
Please name anything that you do not like much about school.
Are there any subjects that you think that you need help with?
Do you receive help in any subjects at school now?
Compared to other people your age, how well do you do in these areas?
  Not As Well As Others About The Same As Others Better Than Most
Reading Speed
Sounding Out Words
Understanding What You Read
Writing Speed
Neatness of Writing
Writing Your Ideas The Way That You Mean
Mathematics
Science
History/Social Studies
Taking Notes In Class
Understanding The Teacher
Paying Attention
Taking Tests
Doing Your Homework
Finishing What You Start
Remembering What You Learn
Remembering Instructions
Sitting Still/Staying In Your Seat
Staying Out Of Trouble
Staying Awake In Class
Playing Group Games and Team Sports
Getting A Joke
Making Friends
Imagining
Please write a sentence about this past weekend.
Do you have any questions about this evaluation?
Please write down anything else about your interests, family, school or feelings.

  

Thank you very much

Mecklenburg Neurological Associates Pediatrics