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Name:
Age:
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Completed by: Self Parent Carer Teacher
Date:
CHARACTERISTICS
Please mouse click in the box if a yes answer to the question:
Are you light sensitive
Bothered by sunlight Bothered by glare Do you frequently wear sunglasses Bothered by bright or fluorescent lights Get a headache from bright or fluorescent lights Feel 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:
Skip words or lines Repeat or reread lines Lose place Read in a "stop and go" rhythm Omit small words Poor reading comprehension Reading becomes harder as you continue Avoid reading for pleasure Rereads for comprehension Reversals of letters and/or numbers
While reading or using a computer, do you:
Rub your eyes Move closer to or further away Squint Open eyes wide Incorporate breaks Change position to reduce glare Close or cover one eye Read word by word Unable to speed read
Do you feel strain, fatigue, tired, or have headaches when:
Reading Listening Doing paper and pencil tasks Working on the computer Watching TV, movies, or live stage production Copying material Playing video games 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 colours and high contrast
Writing:
Write up or down hill Unequal or no spacing between letters or words Unequal letter size Unable to write on the line Problems Proofreading Leave out words, letters, or punctuation marks
Attention/Concentration:
Easily distracted when reading or writing Easily distracted when listening Easily distracted when taking tests Problems staying on task Problems starting tasks
Copying:
Lose place (book, screen, whiteboard, overhead) Leave out words (book, screen, whiteboard, overhead) Slow (book, screen, whiteboard, overhead) Incomplete (book, screen, whiteboard, overhead) Difficulty re-focusing Difficulty copying things onto or from the computer
Mathematics:
Mis-align digits in number columns Difficulty seeing numbers in the correct column Sloppy or careless errors Use finger, graph paper, or other when working with columns of numbers Difficulty seeing signs, symbols, numbers, decimal points Reversals of numbers
Music:
Problems sight reading notes Prefer to memorise 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:
Difficulty getting on and off escalators and other moving objects Clumsy Bump into table edges or door jams Difficulty walking up and/or down stairs Difficulty judging distances Drop or knock things over When walking next to someone, do you drift into the person When walking, do you feel dizzy or light headed
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 Do passengers tell you that you tailgate Are you overly cautious, leaving extra room between you and the car ahead
Sports Performance:
Problems tracking a flying ball in golf, tennis, etc. 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 passing a ball Difficulty playing pool or snooker Difficulty hitting the ball when playing cricket, hockey or tennis
Fatigue While in a Car:
As a passenger, do you become drowsy When driving, do you become drowsy Bothered by glare off the rear window of car in front of you Bothered by headlights and street lights at night Avoid driving at night Have night blindness Bothered by red rear lights on cars Bothered by red traffic lights Stressful to drive in the rain (glare)
If you answered yes to Three or more of these questions in any One of the above sections, then you might be experiencing the effects of a perception problem called Irlen Syndrome/ Scotopic Sensitivity.
Please highlight the complete form, copy and then paste to an email with additional information to
Irlen East
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