
Long Self-Test For Irlen
Syndrome

o
Yes
Please fill out this form. Parents, complete the
form in cooperation with your child.
o
No


Name

Age

Grade
Do you frequently wear sunglasses
Bothered by bright or fluorescent lights
o
Yes
o
No

Tired or drowsy under bright or fluorescent
lights
o
Yes
o
No

Address


Phone
o
Yes
o
No

Completed By

Date


Are you light sensitive?
Yes
o
No
Feel antsy or fidgety under bright or fluorescent
lights
o
Yes
o
No


Get a headache/stomachache from bright or
fluorescent lights
o

NOTE: YOUR EXPERIENCES CAN BE IN
THE PAST,
WHEN IN SCHOOL, AS WELL AS THE
PRESENT.
Become anxious under bright or fluorescent
lights
Bothered by sunlight
Harder to listen under bright or fluorescent
lights
o
Yes
o
Yes
o
No
o
No

Bothered by glare
o
Yes
o
No

o
Performance deteriorates under bright or
fluorescent lights
Yes
o

No
Feel like there is not enough light when reading
o
Yes
o
No
o
Yes

o
No
o
Yes
o
No

Feel like there is too much light when reading
Omit small words
o
Yes

o
No
o
Yes
o
No

Read in dim light
Poor reading comprehension
o
Yes

o
No
o
Yes
o
No

Shade the page with your hand or body
o
Yes
o
No



Reading becomes harder the longer you read
Use your finger or marker to help keep your
place
o
Yes
o
No
Types of reading difficulties:
Skip words or lines

Avoid reading
o
Yes
o
Yes
o
No
o
No

Repeat or reread lines

Avoid reading for pleasure
o
Yes
o
Yes
o
No
o
No

Read with breaks

Rereads for comprehension
o
Yes
o
Yes
o
No
o
No

Lose place

o
Yes
o
Yes
o
No
o
No

Read in a “stop and go” rhythm
Reversals of letters and/or numbers


While reading or using a computer, do
you:
Rub eyes
o
Yes
o
No

Unable to speed read
o
Yes
o
Yes
o
No
o
No

Move closer to or further away
o
Yes
o
No

Squint
o
Yes
o
No

Yes
o
No
Yes
o
No
Yes
o
No
o
Yes
o
No

Listening
o
Yes
o
No

Doing paper and pencil tasks
o
Yes
o
No

Working on the computer
o
Yes
o
No

Watching TV, movies, or live stage productions
Close or cover one eye
o
Yes
o
No

Move head
o
Yes
o
No

Reading
Change position to reduce glare
o


Incorporate breaks
o

Do you feel strain, fatigue, tired, or
have headaches when:
Open eyes wide
o


o
Yes
o
No

Copying material
o
Yes
o
No

Doing math assignments
Read word by word
o
Yes
o

No
Playing video games
o
Yes
o
No
o
Yes

o
No
o
Yes
o
No

Writing long assignments
Unable to write on the line
o
Yes

o
No
o
Yes
Doing visually-intensive activities like
o
No
needlepoint, sewing, cross stitching, crossword
puzzles, woodworking, soldering, etc.

Attention/Concentration:

Problems concentrating with reading or writing

o
Yes
o
No

Working under bright or fluorescent lights
o
Yes
o
No

Looking at stripes, patterns, bright colors, and
high contrast
o
Yes
o
No

Yes
o
No

Handwriting:

Write up or down hill
Yes
o
No
Yes
o
No

Yes
No
o
o
No

o
Yes
o
No

Unequal letter size
Easily distracted when taking tests
o
Yes
Unequal or no spacing between letters or
words
Easily distracted when listening
o
o

Easily distracted when reading or writing
o

o
Leave out words, letters, or punctuation marks
Daydreams in class or at lectures
o
Yes
o
No

Problems staying on task
o
Yes
o
No

Problems starting tasks
o
Yes
No
o
Yes
o
o
No


Difficulty with scantron answer sheets
o
Yes
No
o
Yes
o
o
No


Copying:

Lose place (book, chalkboard, whiteboard,
overhead)
o
Yes
o
No

Leave out words (book, chalkboard,
whiteboard, overhead)
o
Yes
o
No

Yes
o
No

Incomplete (book, chalkboard, whiteboard,
overhead)
Yes
o
No

Composition/Essay Writing:

Disorganized
o
Yes
o
No

Yes
o
No

Careless errors (book, chalkboard, whiteboard,
overhead)
Problems with punctuation
o
Yes
o
No

Problems proofreading
o
Yes
o
No

o
Difficulty copying things onto or off computer or
typewriter
o
Slow (book, chalkboard, whiteboard, overhead)
o
Difficulty refocusing
Leave out letters or words
o
Yes
o
No

Write without rereading
o
Yes
o
Yes
o
No
o
No

Blink or squint (book, chalkboard, whiteboard,
overhead?

Mathematics:

Misalign digits in number columns

Prefer to play by ear
o
Yes
o
Yes
o
No
o
No

Difficulty seeing numbers in the correct column

Use finger to track notes
o
Yes
o
Yes
o
No
o
No

Sloppy or careless errors

Lose your place
o
Yes
o
Yes
o
No
o
No

Use finger, graph paper, or other marker when
working with columns of numbers

Trouble reading the notes or notes and words
together
o
Yes
o
Yes
o
No
o
No

Difficulty seeing signs, symbols, numbers,
decimal points
o
Yes
o
No

Reversals of numbers
o
Yes
o
No


Difficulty interpreting the music notations
o
Yes
o
No

Little progress in spite of regular practice
o
Yes
o
No

Depth Perception:

Difficulty getting on and off escalators
Music:
Problems sight reading the notes
o
Yes
o
No


Prefer to memorize rather than read music
o
Yes
o
No
o
Yes
o
No

Clumsy
o
Yes
o
No

Bump into table edges or door jams
o
Yes
o
No

Difficulty walking up and/or down stairs
o
Yes
o
No

Problems tracking a flying ball like golf,
baseball, or tennis
o
Yes
o
No

Trouble following the ball when watching sports
on TV such as tennis, football or basketball
Difficulty judging distances
o
Yes
o
No


o
Yes
o
No

Drop or knock things over
When watching sports on TV, can you follow
the ball but not see anything else
o
Yes
o
Yes
o
No
o
No

As a child, accident prone or have bruises on
your shins
o
Yes
o
No

When walking next to someone, do you drift
into the person
o
Yes
o
No

When walking, do you feel dizzy or light
headed
o
Yes
o
No

o
Yes
o
No

Afraid of heights
o
Yes
o
No

Sports Performance:
Difficulty playing pool
o
Yes
o
No

Difficulty hitting the ball when playing baseball
or tennis
o
Yes
o
No


Trouble catching or hitting a ball
Trouble learning how to ride a bike
o
Yes
o
No

Trouble jumping rope? Jump in at the wrong
time or jump into the rope
o
Yes
o
No

Trouble playing games such as volley ball or
four square
o
Yes
o
No

On playground equipment such as rings or
bars, was it hard to go from one to the other
o
Yes
o
No

Driving:

Difficulty parallel parking
o
Yes
o
No

Do you feel like you will hit the car in front
when parking
o
Yes
o
No

When parking, do you hit the curb or leave too
much space
o
Yes
o
No

o
Yes
o
No

Yes
o
No

Difficulty judging when to turn in front of
oncoming traffic
Do passengers tell you that you tailgate
o
Yes
o
No

Are you overly cautious, leaving extra room
between you and the car ahead
o
Yes
o
No

Fatigue While In A Car:

As a passenger, do you become drowsy
o
Yes
o
No

o
Are the passengers tense when you make lane
changes
When driving, do you become drowsy
o
Yes
o
No

Bothered by glare on the chrome on cars
o
Yes
o
Yes
o
No
o
No

Uncertain about making lane changes
o
Yes
o
No

Extra cautious when making lane changes

Bothered by glare off the rear window of the
car in front of you
o
Yes
o
No

Stressful to drive in the rain/snow (glare)
o
Yes
o
No

Avoid driving at night
o
Yes
o
No

Bothered by headlights and street lights at
night
o
Yes
o
No

Bothered by tail lights on cars
o
Yes
o
No

Bothered by red/green traffic lights
o
Yes
o
No

Have night blindness
o
Yes
o
No
(Copyright © 1998-2015 by Perceptual Development
Corp/Helen Irlen. All rights reserved.)