Form Wtw 18 - Learning Needs Screening Page 4

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
LEARNING NEEDS SCREENING
(Continued)
EDUCATION:
I
I
14. Were you ever in special education classes in school? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
15. Have you ever been diagnosed or told you have Learning Disabilities? . . . . . . . . . . . . . . . . .
YES
NO
If YES, by whom? ___________________________________________ When? _________
Type(s) of Learning Disabilities (if known): ________________________________________
16. Have you ever been diagnosed or told that you have Attention Deficit Disorder
I
I
with or without hyperactivity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If YES, by whom? ___________________________________________ When? _________
GLASSES:
I
I
17. Do you need or wear glasses or contact lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
18. Was your last vision test within the last two years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
HEARING:
I
I
19. Do you need or wear a hearing aid?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
20. Have you had your hearing tested in the last 12 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SPEECH:
I
I
21. Have you ever seen a speech or language therapist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
MEDICAL/PHYSICAL:
22. Have you ever had any of the following:
I
I
• a lot of ear infections? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• a lot of sinus problems?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• high fevers that lasted a long time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• diabetes (high blood sugar)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• severe allergies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• a lot of headaches or migraines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• a head injury? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• convulsions or seizures? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
• serious health problems?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
I
I
23. Are you taking any medications that affect the way you think, act, or feel? . . . . . . . . . . . . . . .
YES
NO
If YES, what are you taking? __________________________________________________
How often? ________________________________________________________________
I
I
24. Do you need medical or follow-up services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
County referrals needed/made: ________________________________________________
PAGE 4 OF 4
WTW 18 (4/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED

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