The LARS Questionnaire

    Answer YES or NO to the following questions as they pertain to the child. If the question is not appropriate for the child (for example, the child has not learned to read or is not in school), mark the N/A response. Do not leave any question blank.

  1. Is the child male?
    YES   NO   N/A
  2. Is the child female?
    YES   NO   N/A
  3. Does the child have asthma?
    YES   NO   N/A
  4. Has the child been diagnosed as having allergy problems?
    YES   NO   N/A
  5. Does the child have epilepsy?
    YES   NO   N/A
  6. Does the child have a history of stuttering?
    YES   NO   N/A
  7. Does the child have diagnosed hearing loss?
    YES   NO   N/A
  8. Has the child ever been in speech therapy (including currently)?
    YES   NO   N/A
  9. Has the child ever had a fever higher than 105 degrees?
    YES   NO   N/A
  10. Has the child ever been without oxygen for more than a minute?
    YES   NO   N/A
  11. Has the child had tubes in his or her ears more than once?
    YES   NO   N/A
  12. Has the child had a head injury serious enough to require observation?
    YES   NO   N/A
  13. Was the child delivered by C-section?
    YES   NO   N/A
  14. Was the child born more than one month premature?
    YES   NO   N/A
  15. Were forceps used as an aid in the delivery of the child?
    YES   NO   N/A
  16. Did the child have any complications at birth?
    YES   NO   N/A
  17. Has the child changed schools frequently (more than one school a year)?
    YES   NO   N/A
  18. Has the child ever been diagnosed as having an attention deficit disorder?
    YES   NO   N/A
  19. Is the child on medication for hyperactivity or an attentional disorder?
    YES   NO   N/A
  20. Is the child left-handed?
    YES   NO   N/A
  21. Is the child right-handed and left-eye dominant? (To check eye dominance, see which eye the child uses to look through a telescope or a rolled-up sheet of paper.)
    YES   NO   N/A
  22. Is the child left-handed and right-eye dominant?
    YES   NO   N/A
  23. Does the child use the same hand for all activities (for example, drawing, throwing a ball, etc.)?
    YES   NO   N/A
  24. Did the mother smoke one or more cigarettes per day after the third month of pregnancy?
    YES   NO   N/A
  25. Did the mother use alcohol during pregnancy?
    YES   NO   N/A
  26. Did the mother use drugs during pregnancy?
    YES   NO   N/A
  27. Was the child's father using drugs at the time of conception?
    YES   NO   N/A
  28. Did either the mother or the father have difficulty with reading or math while in school (for example, severe enough to repeat a grade or receive special help)?
    YES   NO   N/A
  29. Did the child speak his or her first words by 12 months?
    YES   NO   N/A
  30. Was the child able to walk without support by 14 months?
    YES   NO   N/A
  31. Can the child stand on one leg for 10 seconds without losing his or her balance (two out of three times)?
    YES   NO   N/A
  32. Do you feel that the child is as good as other children his or her age in gross motor skills (for example, throwing or catching a ball)?
    YES   NO   N/A
  33. Do you feel that the child is clumsy?
    YES   NO   N/A
  34. Did the child have a great deal of difficulty learning to ride a bicycle?
    YES   NO   N/A
  35. Does the child get sick in cars or elevators?
    YES   NO   N/A
  36. Does the child have difficulty telling time on a clock with hands?
    YES   NO   N/A
  37. Does the child have poor spelling skills?
    YES   NO   N/A
  38. Can the child remember and repeat four numbers in proper sequence (two out of three times correctly)?
    YES   NO   N/A
  39. Can the child remember and repeat five numbers in proper sequence (two out of three times correctly)?
    YES   NO   N/A
  40. Does the child have difficulty remembering the proper sequence of the letters of the alphabet?
    YES   NO   N/A
  41. Does the child have a difficult time learning how to sound out words (phonics)?
    YES   NO   N/A
  42. Does the child have poor handwriting or drawing skills?
    YES   NO   N/A
  43. Does the child use a finger as a marker while reading?
    YES   NO   N/A
  44. Is the child excessively physically active?
    YES   NO   N/A
  45. Is the child always moving with seemingly limitless energy?
    YES   NO   N/A
  46. Does the child have difficulty understanding the overall meaning of a story?
    YES   NO   N/A
  47. Does the child have poor reading comprehension skills?
    YES   NO   N/A
  48. Was learning the basic shapes of letters and numbers difficult for the child?
    YES   NO   N/A
  49. Does or did the child have difficulty drawing basic shapes such as a square or a triangle? (Most children can copy a circle by age three, a square by age five, and a triangle by age five and a half.)
    YES   NO   N/A

    Answer the following questions as they pertain to the child. If the child wears glasses, answer these questions as if his or her glasses were on. If the question is not appropriate for the child (for example, the child has not learned to read or is not in school), mark the N/A response. Do not leave any question blank.

  50. Does the child complain of blurred vision while reading or writing?
    YES   NO   N/A
  51. Do the child's eyes tire easily when he or she reads?
    YES   NO   N/A
  52. Does the child complain of letters or lines running together or jumping around while reading?
    YES   NO   N/A
  53. Does the child cover or close one eye while reading or watching television?
    YES   NO   N/A
  54. Have you noticed one of the child's eyes turning in or out at any time?
    YES   NO   N/A
  55. Does the child complain of seeing double?
    YES   NO   N/A
  56. Does the child complain of blurred vision when trying to see something far away or the blackboard at school?
    YES   NO   N/A
  57. Has the child ever had vision therapy?
    YES   NO   N/A
  58. Has the child ever been diagnosed as having a lazy eye or amblyoarguments?
    YES   NO   N/A

    Answer the following questions as they pertain to the child. If the question is not appropriate for the child (for example, the child has not learned to read or is not in school), mark the N response. Do not leave any question blank.
    F: Frequently has difficulty in this area
    S: Sometimes has difficulty in this area
    N: Never has difficulty in this area (or not applicable)

  59. Does the child reverse letters or numbers when printing?
    F   S   N
  60. Does the child reverse words during reading?
    F   S   N
  61. Does the child add or substitute letters or words when reading?
    F   S   N
  62. Does the child make errors when copying (for example, the child loses his or her place easily, leaves out letters, or is slow at copying work)?
    F   S   N
  63. Does the child skip words or lines when he or she reads?
    F   S   N
  64. Does the child have difficulty remembering his or her right from left?
    F   S   N
  65. Does the child often fail to finish things he or she starts?
    F   S   N
  66. Is the child easily distracted?
    F   S   N
  67. Does the child have difficulty with tasks requiring sustained attention?
    F   S   N
  68. Does the child have difficulty sticking to a play activity?
    F   S   N
  69. Does the child have difficulty staying seated?
    F   S   N
  70. Does the child seem to fidget constantly?
    F   S   N
  71. Does the child seem not to listen?
    F   S   N
  72. Is the child excessively restless while sleeping?
    F   S   N
  73. Does the child call out in class?
    F   S   N
  74. Does the child often act before thinking?
    F   S   N
  75. Does the child shift excessively from one activity to another?
    F   S   N
  76. Does the child have difficulty organizing work?
    F   S   N
  77. Does the child need a lot of supervision?
    F   S   N
  78. Does the child have difficulty waiting his or her turn in group situations?
    F   S   N
  79. Does the child have difficulty following and comprehending oral instructions?
    F   S   N

    Child's Level:

    The child has not yet started first grade.
    The child is in the first half of first grade.
    The child is in the second half of first grade or has completed first grade.