Case history -Learning disability- Adolescent
I. General Information
1. Child’s Name:
2. Age & DOB:
3. Grade & School:
4. Referral Source: (Parent/Teacher/Pediatrician)
5. Primary Concerns: (Brief description of learning difficulties)
II. Developmental & Medical History
1. Prenatal & Birth History: (Complications, prematurity)
2. Milestones: (Speech, motor, social delays)
3. Medical Conditions: (ADHD, epilepsy, vision/hearing issues)
4. Family History: (LD, ADHD, dyslexia in family)
5. Previous Interventions: (Tutoring, speech therapy, IEP/504)
III. Educational History
1. School Performance: (Grades, teacher feedback)
2. Retention/Drop in Performance: (Any repeated grades?)
3. Special Education Services: (IEP, accommodations)
4. Teacher Observations: (Attention, participation, avoidance behaviors)
IV. Assessment Domains
A. Reading Skills
1. Word Recognition & Fluency
Can the child read grade-level text fluently?
Does the child guess words or skip lines?
Speed: Timed reading (words per minute)
2. Decoding (Phonological Skills)
Non-word reading (e.g., "plont," "stig")
Sound blending (e.g., /k/ /a/ /t/ → "cat")
Phoneme deletion (e.g., "cat" without /k/ = "at")
3. Reading Comprehension
Can the child summarize a passage?
Can they answer literal vs. inferential questions?
Do they remember key details after reading?
B. Writing Skills
1. Handwriting (Dysgraphia Signs)
Legibility: Letter formation, spacing, reversals (b/d, p/q)
Fatigue: Does writing become worse with prolonged tasks?
2. Spelling (Encoding)
Phonetic spelling (e.g., "fone" for "phone")
Irregular word spelling (e.g., "enough," "laugh")
Spelling in isolation vs. sentences
3. Written Expression
Grammar & Syntax: Sentence structure, punctuation
Organization: Paragraph coherence, logical flow
Speed: Time taken to complete writing tasks
C. Mathematics (Dyscalculia Signs)
1. Number Sense & Calculation
Basic operations (+, -, ×, ÷) accuracy & speed
Place value understanding (hundreds, tens, ones)
Number reversals (e.g., 13 vs. 31)
2. Math Fluency
Automaticity: Quick recall of math facts
Use of fingers/compensatory strategies
3. Word Problems & Reasoning
Extracting relevant information
Multi-step problem-solving ability
D. Memory Assessment
1. Working Memory
Digit Span (forward & backward)
Following multi-step instructions (e.g., "Take your book, open to page 10, and
underline the title")
2. Long-Term Memory
Recall of learned facts (e.g., multiplication tables, historical events)
Retrieval difficulties ("I know it but can’t remember now")
3. Verbal vs. Visual Memory
Verbal: Remembering word lists, story details
Visual: Recalling shapes, patterns, spatial layouts
E. Behavioral Observations
1. Attention & Focus:
o Easily distracted?
o Sustains attention in tasks?
2. Frustration & Avoidance:
o Gives up easily on challenging tasks?
o Avoids reading/writing/math?
3. Social Interactions:
o Peer relationships?
o Anxiety about school performance?
F. Executive Functions
1. Planning & Organization
Can they plan a project (e.g., steps for a book report)?
Time management (estimating task duration)
2. Cognitive Flexibility
Can they switch between tasks easily?
Do they perseverate (get stuck on one approach)?
3. Impulse Control
Blurts out answers?
Waits for turn in conversations?
4. Working Memory Load
Forgets instructions midway?
Loses track of multi-step tasks?
V. Standardized Assessments (If Available)
Reading: WIAT, Woodcock-Johnson, GORT (Gray Oral Reading Test)
Writing: TOWL (Test of Written Language)
Math: KeyMath, WIAT Math Subtests
Memory: WISC-V Working Memory Index, WRAML (Wide Range Assessment of
Memory & Learning)
Executive Functions: BRIEF-2 (Behavior Rating Inventory of Executive Function)
