Long Self-Test For Irlen Syndrome

Print this test >> Please fill out this form. Parents, complete the form in cooperation with your child. Name Age Grade Address Phone Completed by Date CHARACTERISTICS Please Check Answer Are you light sensitive? Yes No Bothered by sunlight Bothered by glare Bothered by bright or fluorescent lights Tired or drowsy under bright or fluorescent lights Become anxious under bright or fluorescent lights Get a headache from bright or fluorescent lights Feel antsy or fidgety under bright or fluorescent lights Harder to listen under bright or fluorescent lights Performance deteriorates under bright or fluorescent lights Feel like there is not enough light when reading Feel like there is too much light when reading Read in dim light Use fingers or other marker to block out part of the page Shade the page with your hand or body Types of reading difficulties: Yes No Skip words or lines Repeat or reread lines Read for less than one hour Lose place Read in a “stop and go” rhythm Omit small words Poor reading comprehension Reading becomes harder as you continue Avoid reading Avoid reading for pleasure Rereads for comprehension Reversals of letters and/or numbers While reading or using a computer, do you: Yes No Rub eyes Move closer to or further away Squint Open eyes wide Incorporate breaks Change position to reduce glare Close or cover one eye Move head Read word by word Unable to speed read Do you feel strain, fatigue, tired, or have headaches when: Yes No Reading Listening Doing paper and pencil tasks Working on the computer Watching TV, movies, or live stage productions Copying material Doing math assignments Playing video games Writing long assignments Doing visually-intensive activities like needlepoint, sewing, cross stitching, crossword puzzles, woodworking, soldering, etc. Working under bright or fluorescent lights Looking at stripes, patterns, bright colors, and high contrast Handwriting: Yes No Write up or down hill Unequal or no spacing between letters or words Unequal letter size Unable to write on the line Leave out words, letters, or punctuation marks Attention/Concentration: Yes No Problems concentrating with reading or writing Easily distracted when reading or writing Easily distracted when listening Easily distracted when taking tests Daydreams in class or at lectures Problems staying on task Problems starting tasks Difficulty with scantron answer sheets Copying: Yes No Lose place (book, chalkboard, whiteboard, overhead) Leave out words (book, chalkboard, whiteboard, overhead) Slow (book, chalkboard, whiteboard, overhead) Incomplete (book, chalkboard, whiteboard, overhead) Careless errors (book, chalkboard, whiteboard, overhead) Blink or squint (book, chalkboard, whiteboard, overhead? Difficulty refocusing Difficulty copying things onto or off computer or typewriter Composition/Essay Writing: Yes No Disorganized Problems with punctuation Problems proofreading Leave out letters or words Write without rereading Mathematics: Yes No Misalign digits in number columns Difficulty seeing numbers in the correct column Sloppy or careless errors Use finger, graph paper, or other marker when working with columns of numbers Difficulty seeing signs, symbols, numbers, decimal points Reversals of numbers Music: Yes No Problems sight reading the notes Prefer to memorize rather than read music Prefer to play by ear Use finger to track notes Lose your place Trouble reading the notes or notes and words together Difficulty interpreting the music notations Little progress in spite of regular practice Depth Perception: Yes No Difficulty getting on and off escalators Clumsy Bump into table edges or door jams Difficulty walking up and/or down stairs Difficulty judging distances Drop or knock things over As a child, accident prone or have bruises on your shins When walking next to someone, do you drift into the person When walking, do you feel dizzy or light headed Difficulty getting on or off moving objects Driving: Yes No Difficulty parallel parking Do you feel like you will hit the car in front when parking When parking, do you hit the curb or leave too much space Difficulty judging when to turn in front of oncoming traffic Uncertain about making lane changes Extra cautious when making lane changes Are the passengers tense when you make lane changes Do passengers tell you that you tailgate Are you overly cautious, leaving extra room between you and the car ahead Sports Performance: Yes No Problems tracking a flying ball like golf, baseball, or tennis Trouble following the ball when watching sports on TV such as tennis, football or basketball When watching sports on TV, can you follow the ball but not see anything else Trouble catching or hitting a ball Difficulty playing pool Difficulty hitting the ball when playing baseball or tennis Trouble learning how to ride a bike Trouble jumping rope? Jump in at the wrong time or jump into the rope Trouble playing games such as volley ball or four square On playground equipment such as rings or bars, was it hard to go from one to the other Fatigue While In A Car: Yes No As a passenger, do you become drowsy When driving, do you become drowsy Bothered by glare on the chrome on cars Bothered by glare off the rear window of the car in front of you Bothered by headlights and street lights at night Avoid driving at night Have night blindness Bothered by red tail lights on cars Bothered by red stop lights Stressful to drive in the rain (glare) Scoring: If you answered yes to three or more of the questions in any one of the above sections, then problems in these areas may be helped with Irlen Colored Filters. The higher your score in a section, the more this area is a problem. Click on "Find an Irlen Testing Center" for a certified Irlen practitioner near you.