Learning Disabilities Checklist
The LD Checklist is based on the work of Larry B. Silver: Guide to Learning Disabilities...(2010), & The Misunderstood Child (1992, 2006).
Full Name *
Your answer
Email to receive form results: *
Your answer
Are you completing this checklist for yourself? *
Provide your relationship to the subject, and important details: *
Your answer
Age of subject: *
Your answer
Current school status, city or town, state or province, country: *
Your answer
(1) Visual Perception (Optometrist, Neurologist, Ed Psychologist, Orton-Gillingham Specialist, Occupational Therapist)
(2) Auditory Perception (Audiologist, Speech-Language Pathologist, M.D.-Ears, Nose, Throat Specialist)
(3) Sensory Integration [Sequencing, Abstraction, & Organization] (Occupational Therapist, Ed Psychologist, Neurologist, Orton-Gillingham Specialist, Special Educator, Language Therapist)
1. Visual Perception and Processing Difficulties:[Dyslexia, Dyscalculia, Dysgraphia, Sensory Integration]
2. Auditory Perception and Processing Difficulties: [Auditory Processing Disorder, Dyslexia]
3. Sensory Integration Difficulties:
(4) Sequencing Difficulties: (Ed Psychologist, Neurologist, Orton-Gillingham Specialist, Special Educator)
(5) Abstraction Difficulties: (Ed Psychologist, Neurologist, Orton-Gillingham Specialist, Language Therapist, Special Educator)
(6) Organization Difficulties: (Occupational Therapist)
4. Sequencing Difficulties: [Dyslexia, Dysgraphia, Dyscalculia]
5. Abstraction Difficulties: [Dyslexia, Dyscalculia]
6. Organization Difficulties: [Dyslexia, Dysgraphia, Dyscalculia, ADD]
(7) Short-Term Memory Difficulties: (Neurologist, Ed Psychologist, LD Specialist)
(8) Working Memory Difficulties: (Neurologist, Ed Psychologist, LD Specialist)
(9) Long-Term Memory Difficulties: (M.D., Neurologist, Ed Psychologist, LD Specialist)
LTMD can be temporary or permanent, and can be caused by injury, disease, body chemistry, etc.
7. Short-Term Memory Difficulties:
8. Working-Memory Difficulties:
9. Long-Term Memory Difficulties:
(10) Language Difficulties (Audiologist, Speech-Language Pathologist)
(11) Motor Difficulties (Neurologist, Occupational Therapist, Physical Therapist, Educational Therapist)
10. Language Difficulties:
11. Motor Difficulties:
Add important information about subject's health history, diagnoses, interventions, etc.
Your answer
Upon submission, you will receive an email of your LD checklist, which also contains a PDF of the checklist attached.

Use it to seek help from a properly qualified specialist.

Never submit passwords through Google Forms.
This form was created inside of Dyscalculia.org.