Form Wtw 19 - Learning Needs Screening (Page 3 of 3) in pdf

Form Wtw 19 - Learning Needs Screening Page 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

LEARNING NEEDS SCREENING

CLIENT COPY

(Continued)

16. Have you ever been diagnosed or told that you have Attention Deficit Disorder with

or without hyperactivity?

If YES, by whom?

When?

17. Do you need or wear glasses or contact lenses?

18. Was your last vision test within the last two years?

19. Do you need or wear a hearing aid?

20. Have you had your hearing tested in the last 12 months?

21. Have you ever seen a speech or language therapist?

22. Have you ever had any of the following:

•

a lot of ear infections

• a lot of headaches or migraines

•

a lot of sinus problems

• a head injury

•

high fevers that lasted a long time

• convulsions or seizures

•

diabetes (high blood sugar)

• serious health problems

•

severe allergies

23. Are you taking any medications that affect the way you think, act, or feel?

If YES, what are you taking?

How often?

24. Do you need medical or follow-up services?

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WTW 19 (11/15) REQUIRED FORM - NO SUBSTITUTES PERMITTED

Form Wtw 19 - Learning Needs Screening Page 3