Children’s Nonverbal Learning Disabilities Scale
by David B. Goldstein, Ph.D.
Parents: Please answer all of the following questions.
NAME OF CHILD: ________________________________________________
DATE OF BIRTH: ____________________ AGE: ____________ SEX________
GRADE: _______ SCHOOL: ________________________________________
HANDEDNESS: RIGHT ________ LEFT _________ BOTH ________
This Questionnaire has been completed by:
Mother __________ Father __________
Other (Please Describe your relationship) ___________________________
1. Motor Skills
a. My child has problems with balance (e.g. never learned to ride a bike).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
b. My child displays impaired fine motor skills (e.g. significant difficulties learning to tie shoes).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
c. My child has problems writing or extremely slow writing.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
d. My child seems unusually clumsy.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
2. Visual-Spatial Skills
a. My child has difficulty remembering and organizing visual or spatial information (e.g. has difficulty lining up numbers to do a math problem or lining up words neatly on a page).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
b. My child appears disoriented, lost, or confused when entering a new situation.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
c. My child is slow to become familiar with new physical locations (e.g. continues to appear lost or disoriented after repeated exposures to the same location).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
d. My child has difficulty remembering the faces of people he or she has met.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
e. My child has an auditory memory like a tape recorder.
Yes____ No____ I don’t know____
f. My child loses his or her way and needs help finding his or her way around.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
g. My child has unusually strong verbal skills (e.g. an impressive vocabulary or early speech).
Yes____ No____ I don’t know____
3. Interpersonal Skills
a. My child often does not get the humor in a joke because he or she interprets everything so literally.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
b. When interacting with others my child has difficulty reading the other person’s non-verbal cues, such as tone of voice or facial expression.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
c. My child interprets what I say very literally (for example, if I tell my child ‘to pick themselves up by his or her bootstraps, they appear confused).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
d. My child has difficulty transferring what he or she learns in one social situation to similar social situations. For e.g. my child appears confused when confronted with slight changes in a frequently encountered social situation.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
NAME OF CHILD: ________________________________________________
DATE OF BIRTH: ____________________ AGE: ____________ SEX________
GRADE: _______ SCHOOL: ________________________________________
HANDEDNESS: RIGHT ________ LEFT _________ BOTH ________
This Questionnaire has been completed by:
Mother __________ Father __________
Other (Please Describe your relationship) ___________________________
1. Motor Skills
a. My child has problems with balance (e.g. never learned to ride a bike).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
b. My child displays impaired fine motor skills (e.g. significant difficulties learning to tie shoes).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
c. My child has problems writing or extremely slow writing.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
d. My child seems unusually clumsy.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
2. Visual-Spatial Skills
a. My child has difficulty remembering and organizing visual or spatial information (e.g. has difficulty lining up numbers to do a math problem or lining up words neatly on a page).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
b. My child appears disoriented, lost, or confused when entering a new situation.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
c. My child is slow to become familiar with new physical locations (e.g. continues to appear lost or disoriented after repeated exposures to the same location).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
d. My child has difficulty remembering the faces of people he or she has met.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
e. My child has an auditory memory like a tape recorder.
Yes____ No____ I don’t know____
f. My child loses his or her way and needs help finding his or her way around.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
g. My child has unusually strong verbal skills (e.g. an impressive vocabulary or early speech).
Yes____ No____ I don’t know____
3. Interpersonal Skills
a. My child often does not get the humor in a joke because he or she interprets everything so literally.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
b. When interacting with others my child has difficulty reading the other person’s non-verbal cues, such as tone of voice or facial expression.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
c. My child interprets what I say very literally (for example, if I tell my child ‘to pick themselves up by his or her bootstraps, they appear confused).
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____
d. My child has difficulty transferring what he or she learns in one social situation to similar social situations. For e.g. my child appears confused when confronted with slight changes in a frequently encountered social situation.
Never/Rarely___ Sometimes____ Often/Always____ I don’t know____