CONFIDENTIAL QUESTIONNAIRE FOR ADULTS & POST 16 

PERSONAL DETAILS  

EMPLOYMENT/CONTINUING EDUCATION  

Yes
No
Yes
No
Part time
Full time
College
University

SCHOOL HISTORY  

Yes
No
Yes
No
Yes
No
Did you have any difficulties at school with any of the following?  
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Yes
No
Yes
No
Yes
No
Yes
No

BACKGROUND INFORMATION  

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

CURRENT DIFFICULTIES  

ln day to day experiences at work, or on courses you have taken, have you had difficulties with any of the following: 
 
Communication - do you: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Organisation - do you have problems with: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Memory and Concentration:  
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Literacy - do you have problems with: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 
Orientation: 
Yes
No
Yes
No
Yes
No
Yes
No
 
Arithmetic - do you: 
Yes
No
Yes
No
Yes
No
 
Coordination and Dexterity - do you: 
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No