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HOME
About Us
Irlen Syndrome
Diagnosis & Solutions
Find a Clinic
Blog
Resources
Shop (Qld and NT only)
Contact

USER TEST FORM

SELF TEST FORM

You can fill in the form and submit the Self Test to the Clinic of your choice or you can download the Self Test and complete and bring to your appointment.

– Step 1 of 15

Name *

Age

Grade

Address

Address Line 1

City

State / Province / Region

Email *

Phone

Form completed by

Select Clinic *

Are you light sensitive?

Bothered by sunlight

Yes
No
?

Bothered by glare

Yes
No
?

Bothered by bright or fluorescent lights

Yes
No
?

Tired or drowsy under bright or fluorescent lights

Yes
No
?

Become anxious under bright or fluorescent lights

Yes
No
?

Get a headache from bright or fluorescent lights

Yes
No
?

Feel antsy or fidgety under bright or fluorescent lights

Yes
No
?

Harder to listen under bright or fluorescent lights

Yes
No
?

Performance deteriorates under bright or fluorescent lights

Yes
No
?

Feel like there is not enough light when reading

Yes
No
?

Feel like there is too much light when reading

Yes
No
?

Read in dim light

Yes
No
?

Use fingers or other marker to block out part of the page

Yes
No
?

Shade the page with your hand or body

Yes
No
?

Types of reading difficulties:

Skip words or lines

Yes
No
?

Repeat or rereads lines

Yes
No
?

Read for less than one hour

Yes
No
?

Lose place

Yes
No
?

Read in a "stop and go" rhythm

Yes
No
?

Omit small words

Yes
No
?

Poor reading comprehension

Yes
No
?

Read progressively worse as reading continues

Yes
No
?

Avoid reading

Yes
No
?

Avoid reading for pleasure

Yes
No
?

While reading or using a computer, do you:

Rub eyes

Yes
No
?

Move closer to or further away

Yes
No
?

Squint

Yes
No
?

Open eyes wide

Yes
No
?

Incorporate breaks

Yes
No
?

Move around to reduce glare

Yes
No
?

Close or cover one eye

Yes
No
?

Move head

Yes
No
?

Read word by word

Yes
No
?

Unable to skim or speed read

Yes
No
?

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

Reading

Yes
No
?

Listening

Yes
No
?

Doing paper and pencil tasks

Yes
No
?

Working on the computer

Yes
No
?

Watching TV or movies

Yes
No
?

Copying material

Yes
No
?

Doing math assignments

Yes
No
?

Playing video games

Yes
No
?

Writing long assignments

Yes
No
?

Doing visually intensive activities like needlepoint, sewing,cross stitching, reading tape measures etc.

Yes
No
?

Working under bright or fluorescent lights

Yes
No
?

Handwriting:

Write up or down hill

Yes
No
?

Unequal or no spacing between letters or words

Yes
No
?

Unequal letter size

Yes
No
?

Unable to write on the line

Yes
No
?

Difficulty with multiple choice answer sheets

Yes
No
?

Leave out words, letters, or punctuation marks

Yes
No
?

Attention/Concentration:

Problems concentrating with reading or writing

Yes
No
?

Easily distracted when reading or writing

Yes
No
?

Easily distracted when listening

Yes
No
?

Daydreams in class

Yes
No
?

Problems staying on task

Yes
No
?

Problems starting tasks

Yes
No
?

Copying:

Lose place (book, chalkboard, whiteboard, overhead)

Yes
No
?

Leave out words (book, chalkboard, whiteboard, overhead)

Yes
No
?

Slow (book, chalkboard, whiteboard, overhead)

Yes
No
?

Incomplete (book, chalkboard, whiteboard, overhead)

Yes
No
?

Careless errors (book, chalkboard, whiteboard, overhead)

Yes
No
?

Blink or squint (book chalkboard, whiteboard, overhead)

Yes
No
?

Difficulty refocusing

Yes
No
?

Difficulty copying things onto computer or typewriter

Yes
No
?

Writing:

Disorganized

Yes
No
?

Problems with punctuation

Yes
No
?

Problems proofreading

Yes
No
?

Leave out letters or words

Yes
No
?

Write without rereading

Yes
No
?

Mathematics:

Misalign digits in number columns

Yes
No
?

Difficulty seeing numbers in the correct column

Yes
No
?

Sloppy or careless errors

Yes
No
?

Use finger, graph paper, or other marker when working with columns of numbers

Yes
No
?

Difficulty seeing signs, symbols, numbers, decimal points

Yes
No
?

Reversals of numbers

Yes
No
?

Music:

Problems sight reading the notes

Yes
No
?

Prefer to memorize rather than read music

Yes
No
?

Prefer to play by ear

Yes
No
?

Use finger to track notes

Yes
No
?

Lose your place

Yes
No
?

Trouble reading the notes

Yes
No
?

Difficulty interpreting the music notations

Yes
No
?

Little progress in spite of regular practice

Yes
No
?

Depth Perception:

Difficulty getting on and off escalators

Yes
No
?

Clumsy

Yes
No
?

Bump into table edges or door jams

Yes
No
?

Difficulty walking up and or down stairs

Yes
No
?

Difficulty judging distances

Yes
No
?

Drop or knock things over

Yes
No
?

As a child, accident prone or have bruises on your shins

Yes
No
?

When walking next to someone, do you drift into the person

Yes
No
?

When walking, do you feel dizzy or light headed

Yes
No
?

Difficulty getting on or off moving objects

Yes
No
?

Driving:

Difficulty parallel parking

Yes
No
?

Do you feel like you will hit the car in front when parking

Yes
No
?

When parking, do you hit the curb or leave too much space

Yes
No
?

Difficulty judging when to turn in front of oncoming traffic

Yes
No
?

Uncertain about making lane changes

Yes
No
?

Trouble jumping rope? Jump in at the wrong time or jump into the rope

Yes
No
?

Extra cautious when making lane changes

Yes
No
?

Are the passengers tense when you make lane changes

Yes
No
?

Do passengers tell you that you tailgate

Yes
No
?

Are you overly cautious, leaving extra room between you and the car ahead

Yes
No
?

Sports Performance:

As a child, problem catching a small fly ball

Yes
No
?

Trouble following the ball when watching sports on TV such as tennis, football or basketball

Yes
No
?

When watching sports on TV, can you follow the ball but not see anything else

Yes
No
?

Difficulty playing pool

Yes
No
?

Difficulty knowing when to hit the ball when playing tennis

Yes
No
?

Trouble learning how to ride a bike

Yes
No
?

Trouble playing games such as volley ball or four square

Yes
No
?

On playground equipment such as rings or bars, was it hard to go from one to the other

Yes
No
?

Fatigue while In A Car:

Become drowsy when you are a passenger

Yes
No
?

Become drowsy when driving

Yes
No
?

Bothered by chrome on cars

Yes
No
?

Bothered by glare off the windshield of the car in front of you

Yes
No
?

Bothered by headlights and street lights

Yes
No
?

Avoid driving at night

Yes
No
?

Have night blindness

Yes
No
?

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