CPI Self Entry

FREE CPI On-Line Learning Style/Disability Rating

Please provide the following information.

When finished, click the "Submit Rating" button at the bottom of the page to view the report.

 
First Name:
 
Last Name:
 
Grade (if in school):
 
Age:
 
Sex:
MaleFemale
 
State in which you live:
 
Hand used for writing/drawing:
RightLeftBoth
 
Primary Ethnic Origin:
WhiteBlackHispanic/LatinoAsianAm IndianMixed
 
Is any medication taken on a regular basis? If so, for what?
NoADD/ADHDAllergyGrowthEmotion/Behavior
 
Have you ever received any of these Special Education Services?
NoLDEBDSpeech/LangOHI
 
Are there other family members with learning difficulties?
NoParentSiblingAunt/UncleGrandparent
 
Were there any complications before or during birth?
YesNo?
 
Has there ever been a serious head injury?
YesNo?
 
Has there ever been any medical issue that may have affected the brain?
YesNo?
 
Did you have many ear infections during infancy or childhood?
YesNo?
 
Is there an identified or suspected attention deficit disorder (ADD or ADHD)?
YesNo?
 
Do you have an identified or suspected Learning Disability?
YesNo?
 
In your opinion, are there any behavior problems which may interfere in school?
YesNo?
 
Is there a visual problem that is not fully correctable with glasses?
YesNo?
 
Is there any hearing problem that is not fully corrected?
YesNo?
 
Have you been absent from school more than most other students?
YesNo?
 
Are you fluent in the English language?
YesNo?
 
What is the primary language spoken in your home?
EnglishOther
 
How many years of education in English have you received?
 

For the following 50 items please select the rating that best describes you based on the scale to the right.

Please complete all items for an accurate rating, then click the "Submit Rating" button at the bottom of the page.

1

Obvious Difficulty

2

Apparent Weakness

3

Average or Uncertain

4

Not a Problem

5

Obvious Strength

1

Ability to understand or remember questions, directions, or verbal instructions. Like when a teacher is just lecturing without any charts or pictures.

12345
2

Ability to quickly think through a difficult problem or situation. Does a better answer come later in the day or even the next day?

12345
3

Ability to remember new phone numbers and/or addresses.

12345
4

Ability to remember or understand the basic idea of what happened in a movie or story - general information rather than specific details.

12345
5

Ability to remember the names of characters or other specific details in a story or movie.

12345
6

Ability to get or stay organized. Does organization come easily?

12345
7

Ability to pay attention to instruction, activities or games.

12345
8

Ability to remember or follow complex directions or requests (involving 3 or more steps). Does the request need to be repeated?

12345
9

Ability to read quickly and fluently.

12345
10

Ability to quickly sound out new words.

12345
11

Ability to understand what is read just using the "context" (without pictures).

12345
12

Ability to understand what is read when there are pictures for clues.

12345
13

Handwriting neatness.

12345
14

Writing mechanics (spelling, punctuation, capitalization, etc.).

12345
15

Writing content. Ability to express ideas in writing when the "mechanics" don't matter.

12345
16

Letter/word orientation. This is a "difficulty" if letters are ever reversed (b/d, etc.), out of order in words or starting words with the wrong letter.

12345
17

Ability to remember specific formulas for solving math problems.

12345
18

Ability to estimate or figure out the answer to math problems without using a specific formula.

12345
19

Verbal speed - ability to talk quickly and clearly.

12345
20

Verbal fluency without noticeable pauses or groping for words. Is it difficult to come up with the right words to express a thought?

12345
21

Ability to solve visual, mechanical, or "hands on" puzzles or problems.

12345
22

Ability to recognize voices (like on the telephone).

12345
23

Ability to stay focused and recheck tasks without making careless mistakes.

12345
24

Ability to be creative and come up with new ideas or new ways of doing something.

12345
25

General sense of humor. Do you see humor in lots of situations or have difficulty understanding what others think is funny?

12345
26

Rhythmic or musical skills (even if an instrument is not played).

12345
27

Ability to "plan" and to break large tasks into smaller parts or steps.

12345
28

Arts and crafts skills (drawing, painting, sculpture, etc.).

12345
29

Ability to visualize and imagine things in his/her head (pictures, faces, words, numbers, etc.)?

12345
30

Ability to accomplish long-term goals or projects.

12345
31

Directional skills (right/left, north/south, etc.).

12345
32

Ability to complete jigsaw puzzles.

12345
33

Ability to remember the words of new popular songs?

12345
34

Ability to remember the tunes to new popular songs?

12345
35

Ability to cope with an unexpected change in plans.

12345
36

Ability to cope with transitions from one activity to another.

12345
37

Ability to remember the rules to games.

12345
38

Ability to keep up with activities. Are you the first to start and/or finish something (4 or 5) or are others kept waiting (1 or 2)?

12345
39

Ability to sit still for long periods of time?

12345
40

Ability to control emotions and avoid overreacting to situations.

12345
41

Ability to cope with disappointment.

12345
42

Ability to begin tasks without being told or reminded.

12345
43

Ability to keep busy to avoid being bored.

12345
44

Ability to stick with or follow a schedule for homework or chores.

12345
45

Awareness of homework assignments.

12345
46

Ability to find or gather necessary materials to complete chores or assignments.

12345
47

Ability to keep room or desk clean and organized.

12345
48

Awareness of how your behavior affects others.

12345
49

Sensitivity to the feelings of others.

12345
50

Ability to stick with a difficult or unpleasant task.

12345
 
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