Using Self Tests to Check Your Symptoms - Irlen Ballarat

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Certified Irlen® Diagnostician & Educational Consultant

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The Irlen® Self Tests

These simple Yes/No tests, which you can complete at home in your own time are intended to provide an indication about whether you may need to consider professional screening for Irlen® Syndrome. I ask for your contact details so that I can contact you to discuss the screening results with you, in confidence.

You are under no obligation to undertake a full screening assessment; nor will your details be used to promote my services in the future. Most importantly your contact details will not be passed onto any third parties. If, as a result of completing this form and discussing the results you decide to go no further with the process then the information and the form will be destroyed.

Please complete the form below. Once I have reviewed your answers, I will contact you to discuss the screening results with you.

NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.

Take the Irlen® Self Test

Client's Name *

First

Last

Please put your child’s name here if you are completing on behalf of your child.

Client's Age *

Year at School (if applicable)

Parent / Guardian Name if Client is under 18

Contact Phone Number *

Email *

Are you light sensitive? *

Bothered by sunlight
Bothered by glare
Do you frequently wear sunglasses
Bothered by bright or fluorescent lights
Tired or drowsy under bright or fluorescent lights
Become anxious under bright or fluorescent lights
Get a headache/stomachache 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
Shade the page with your hand or body
None of the above

Please tick the options that you answer ‘yes’ to

Types of reading difficulties: *

Skip words or lines
Repeat or reread lines
Read with breaks
Lose place
Read in a “stop and go” rhythm
Omit small words
Poor reading comprehension
Reading becomes harder the longer you read
Use your finger or marker to help keep your place
Avoid reading
Avoid reading for pleasure
Rereads for comprehension
Reversals of letters and/or numbers
None of the above

Please tick the options that you answer ‘yes’ to

While reading or using a computer, do you: *

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
None of the above

Please tick the options that you answer ‘yes’ to

Do you feel strain, fatigue, tired, or have headaches when: *

Reading
Listening
Doing paper and pencil tasks
Reading on the computer / iPad / iPhone / Tablet
Watching TV, movies, or live stage productions
Copying material
Doing math assignments
Playing video games
Writing essays
Doing visually-intensive activities like needlepoint, sewing, cross stitching, crossword puzzles, woodworking, soldering, etc.
Reading under bright or fluorescent lights
Looking at stripes, patterns, polka dots, fluorescent colors
None of the above

Please tick the options that you answer ‘yes’ to

Handwriting: *

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
None of the above

Please tick the options that you answer ‘yes’ to

Attention/Concentration: *

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
None of the above

Please tick the options that you answer ‘yes’ to

Copying: *

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
None of the above

Please tick the options that you answer ‘yes’ to

Composition/Essay Writing: *

Disorganized
Problems with punctuation
Problems proofreading
Leave out letters or words
Write without rereading
None of the above

Please tick the options that you answer ‘yes’ to

Mathematics: *

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
None of the above

Please tick the options that you answer ‘yes’ to

Music: *

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
None of the above

Please tick the options that you answer ‘yes’ to

Depth Perception: *

Difficulty getting on and off escalators
Clumsy
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
Afraid of heights
None of the above

Please tick the options that you answer ‘yes’ to

Sports Performance: *

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
None of the above

Please tick the options that you answer ‘yes’ to

Driving: *

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
Trouble jumping rope? Jump in at the wrong time or jump into the rope
Do passengers tell you that you tailgate
Are you overly cautious, leaving extra room between you and the car ahead
None of the above

Please tick the options that you answer ‘yes’ to

Fatigue While In A Car: *

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
Stressful to drive in the rain/snow (glare)
Avoid driving at night
Bothered by headlights and street lights at night
Bothered by tail lights on cars
Bothered by red/green traffic lights
Have night blindness
None of the above

Please tick the options that you answer ‘yes’ to

Please add any additional information you think may be relevant:

Name

Take the Irlen® Self Test for Headaches

Do any of the following bother your eyes, head, and stomach; make you dizzy, tired, nervous, anxious or irritable?

Reading textbooks for extended periods? *

Yes
No

Reading on a computer for extended periods? *

Yes
No

Working or reading under fluorescent lights? *

Yes
No

Reading black print on high gloss white paper? *

Yes
No

Doing visually-intensive activities like needlepoint, cross stitching, woodworking, crossword puzzles? *

Yes
No

Bothered by sunlight? *

Yes
No

Bothered by glare outside; glare off chrome on cars? *

Yes
No

Bothered by glare off high gloss white paper? *

Yes
No

Bothered by glare on hazy days? *

Yes
No

Bothered by bright lights? *

Yes
No

Bothered by fluorescent lights? *

Yes
No

Bothered by headlights from oncoming traffic? *

Yes
No

Certain patterns or stripes bother you? *

Yes
No

Bright or neon colors bother you? *

Yes
No

Do you frequently wear sunglasses? *

Yes
No

Do you become tired or drowsy under bright or fluorescent lighting? *

Yes
No

Do you get a headache from fluorescent lighting? *

Yes
No

Do you feel antsy or fidgety when under fluorescent lighting? *

Yes
No

Does your performance deteriorate under bright or fluorescent lighting? *

Yes
No

Do you feel like there is too much light when reading? *

Yes
No

Do you feel like there is not enough light when reading? *

Yes
No

Do you read in dim lighting? *

Yes
No

Do you feel like you need less light to read? *

Yes
No

Name *

First

Last

Email *

Please provide a valid email address so I can contact you with your results.

Comment

self test for Irlen Sydnrome

Content Source: Irlen.com

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