Tailored Reading  
Pupil Information Questionnaire
(Use the back if needed)

Tutor _______________________________                                                                              Date ___________
Pupil _______________________________                         Age ___________                     DOB_____________
School ______________________________  Teacher _______________________  Grade ______ Class ______
Additional school information ___________________________________________________________________

1. About your family:
Mom: _____________________________________________________________________________________
Dad: ______________________________________________________________________________________
Brother(s) (ages) _____________________________________________________________________________
Sister(s) (ages) _______________________________________________________________________________
Other ______________________________________________________________________________________

2. What pet(s) do you have? Tell about them. ________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
or, what pet would you like to have? ________________________________________________________________
Why? _______________________________________________________________________________________
____________________________________________________________________________________________

3. What do you like to do in school that is fun? _______________________________________________________
____________________________________________________________________________________________

4. What do you like to do at home that is fun? ________________________________________________________
____________________________________________________________________________________________

5. Favorites (more than one of each is fine):
Movie ____________________________________   Color ____________________________________________
Friend ____________________________________   Book/Story _______________________________________
Food _____________________________________   T.V. Program _____________________________________
Teacher ___________________________________   Game ___________________________________________
Song _____________________________________    Rainy day activity __________________________________
Other _______________________________________________________________________________________

6. Do you like to read? _____ To be read to? ___ What kind of books do you like? ___________________________
____________________________________________________________________________________________

7. What do you think makes a person a good reader? ___________________________________________________
____________________________________________________________________________________________  

8. Is there anything else that you want to tell me about yourself?__________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________