Long Self-Test For Irlen Syndrome Please fill out this form. Parents, complete the form in cooperation with your child. Step 1 of 15 6% Name First Last AgeGradeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneCompleted ByDate DD slash MM slash YYYY Are you light sensitive?NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.Bothered by sunlight Yes No Bothered by glare Yes No Do you frequently wear sunglasses 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/stomachache 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 Shade the page with your hand or body Yes No Types of reading difficulties:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.Skip words or lines Yes No Repeat or reread lines Yes No Read with breaks 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 Reading becomes harder the longer you read Yes No Use your finger or marker to help keep your place Yes No Avoid reading Yes No Avoid reading for pleasure Yes No Rereads for comprehension Yes No Reversals of letters and/or numbers Yes No While reading or using a computer, do you:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.Rub eyes Yes No Move closer to or further away Yes No Squint Yes No Open eyes wide Yes No Incorporate breaks Yes No Change position to reduce glare Yes No Close or cover one eye Yes No Move head Yes No Read word by word Yes No Unable to speed read Yes No Do you feel strain, fatigue, tired, or have headaches when:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.Reading Yes No Listening Yes No Doing paper and pencil tasks Yes No Reading on the computer / iPad / iPhone / Tablet Yes No Watching TV, movies, or live stage productions Yes No Copying material Yes No Doing math assignments Yes No Playing video games Yes No Writing essays Yes No Doing visually-intensive activities like needlepoint, sewing, cross stitching, crossword puzzles, woodworking, soldering, etc. Yes No Reading under bright or fluorescent lights Yes No Looking at stripes, patterns, polka dots, fluorescent colors Yes No Handwriting:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.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 Leave out words, letters, or punctuation marks Yes No Attention/Concentration:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.Problems concentrating with reading or writing Yes No Easily distracted when reading or writing Yes No Easily distracted when listening Yes No Easily distracted when taking tests Yes No Daydreams in class or at lectures Yes No Problems staying on task Yes No Problems starting tasks Yes No Difficulty with scantron answer sheets Yes No Copying:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.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 or off computer or typewriter Yes No Composition/Essay Writing:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.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:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.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:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.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 or notes and words together Yes No Difficulty interpreting the music notations Yes No Little progress in spite of regular practice Yes No Depth Perception:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.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 Afraid of heights Yes No Sports Performance:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.Problems tracking a flying ball like golf, baseball, or tennis 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 Trouble catching or hitting a ball Yes No Difficulty playing pool Yes No Difficulty hitting the ball when playing baseball or tennis Yes No Trouble learning how to ride a bike Yes No Trouble jumping rope? Jump in at the wrong time or jump into the rope 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 Driving:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.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 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 Fatigue While In A Car:NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.As a passenger, do you become drowsy Yes No When driving, do you become drowsy Yes No Bothered by glare on the chrome on cars Yes No Bothered by glare off the rear window of the car in front of you Yes No Stressful to drive in the rain/snow (glare) Yes No Avoid driving at night Yes No Bothered by headlights and street lights at night Yes No Bothered by tail lights on cars Yes No Bothered by red/green traffic lights Yes No Have night blindness Yes No If you would like to receive a copy of your test so you can review your results later, enter your email address in the space provided (optional). 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