Completed by Date Approximate Grade Achievement Rate the areas of concern (1=mild, 2=moderate, 3=severe) Reading difficulty with alphabet recognition. poor symbol association. has difficulty in sound blending. confuses visually similar words. reverses words in reading. omits/adds/skips sounds, letters, or words. has difficulty with sight vocabulary. word guesser. Comments: difficulty demonstrating word comprehension. forgets what is read orally. understands what is read to him/her, but not what he/she reads silently. does not comprehend what he/she reads. difficulty comprehending particular content area. – name content area difficulty with main idea, supporting details, context, clues, and drawing conclusions. Comments: place when reading.. does not read independently. read words correctly in one context, but not in another. reads word-by-word or sound-by-sound. slow reading rate. difficulty taking tests. Comments: SUGGESTED READING INTERVENTIONS change reading group/additional support. peer or tutoring. parent involvement/reinforcement/follow-up. modify worksheet or workbook. E. use study carrel to improve environment for conc concentration. F. use of reinforcers/behavior modification techniques/contracts. G. cooperative learning techniques. read along with taped readings. phrase/sentence strips. one-to-one assistance. Referral to reading specialist or reading specialist or reading achievement lab. The Pre-Referral Intervention Manual.
Known allergies: Regular medications: History of seizures/convulsions: Age of onset: Frequency: What does your child eat: How does your child eat: Concerns: When does your child sleep at night: How long: When does your child nap: How long: Frequency: Concerns: Other Information: Vision formally checked? Results: Date of last exam: Concerns: Hearing formally checked? Results: Date of last exam: Concerns: History of ear infections? Age: Ear tube placement? Date:
Sometimes says “No” when interfered with Yes No Kicks a ball Yes No Gets self up to a standing position Yes No Points to at least three body parts, such as eyes, nose, mouth, hands, feet, etc. when asked to do so Yes No Uses at least five words Yes No Turns pages of picture-books on page at a time Yes No Runs Yes No Opens doors by turning knob Yes No Names at least three body parts when asked to do so Yes No Offers to help others Yes No Understands the meaning of “up” and “down” Yes No Identifies at one color correctly Yes No Uses at least ten words Yes No Uses at one word, such as me, I, he, she, you, it Yes No Puts two sentences together with the “and”, “or”, or “but” Yes No Stands without support Yes No Follows simple instructions Yes No Uses the words “fast” and “slow” correctly Yes No a few familiar objects in picture books Yes No Plays with other children Yes No Points to or names the bigger of two objects when asked to do so Yes No Hands a toy to you when asked to Yes No Claps hands Yes No Feeds self with a spoon Yes No Recalls past events: says things like, “Remember when we went…” Yes No Asks for “more” or “another-one” Yes No “bye-bye” or “good-bye” Yes No Tattles or tells on other children Yes No Uses the words “you” in sentences Yes No Walks up and down stairs alone Yes No Builds a tower of two or more blocks Yes No Eats with a fork Yes No simple songs Yes No Responds to simple questions appropriately with “yes” or “no” Yes No Toilet trained for bladder control Yes No