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Student's Name
   
 
 
 
Student's date of birth?
MonthDayYear
  
 
 
 
Do you live on Joint Base Andrews?
Yes
No
 
 
 
Members of the Household (include ages of minors)
   
 
 
 
Languages spoken in the home?
   
 
 
 
How often does someone read with you?
 
 
 
Do you enjoy reading or being read to?
Extremely Dislike
Dislike
Neutral
Like
Extremely Like
 
 
How do you feel about each subject?
Reading
Math
Science
Social Studies
Health
 
 
How do you feel about the following:
Dislike Neutral Like
Working independently
Working in a group
 
 
How is your attention span?
Easily Distracted Neutral Focused
Attention Span
-