The Irlen Self Test:


Certified by The Irlen® Institute International.

Irlen Manchester

The Irlen® Self-Test



Name of person to be screened:.........................................................

Client DOB:.....................................................................................

Name of Parent/Guardian if applicable:...............................................

Contact Telephone number:..............................................................

Contact email address:.....................................................................


ENVIRONMENT/DEPTH PERCEPTION

Do you:

Hold onto the railing/wall going up and down the stairs?   

Trip up at the top or bottom of the stairs?   

Sometimes think there is another step but there isn’t?   

Bump into the edges of furniture or doorways by accident?   

When walking with people you tend to walk into them?   

When walking do you tend to veer off to one side?   

Was learning to ride a bike difficult because of poor balance?   

Still have difficulty going in a straight line on a bike?   

Tend to hit the kerb if riding a bike too close to the kerb?   

Hesitate when using escalators?   

Feel dizzy on heights or ladders?   

Have difficulty catching a ball?   

Feel clumsy or accident prone?   

Feel dizzy/light-headed when walking around normally?   

Have difficulty skipping or jumping?   

Have difficulty with merry-go-rounds or rides at fairs?   

Drop things easily or knock things over easily?   

Put things too close to table edges or other surfaces?   

Tend to be extra cautious when parking or overtaking cars?   

Find it difficult to judge the speed of other cars?   

Find it difficult to drive and take in things around you?   


WHEN YOU ARE READING:

Do you:

Enjoy reading?   

Use a marker/finger to keep your place?   

Easily lose your place?   

Skip lines?   

Skip words?   

Re-read lines by mistake?   

Re-read lines for meaning?   

Read for only a short time?   

Find reading gets worse with time?   

Find that words look different or change after a while?   

Shade the page to reduce glare?   

Move closer to the page?   

Move further from the page?   

Become restless?   

Become easily distracted?   


STRAIN AND FATIGUE ASSOCIATED WITH READING, COMPUTER OR OTHER ACTIVITIES

Do You:

Need to take frequent breaks?  

Rub your eyes?  

Frown or squint?  

Blink frequently?  

Open eyes wide?  

Feel drowsy?  

Feel dizzy?  

Feel nauseous?  

Get a headache?

Do your:

Eyes feel tired or strained?  

Eyes hurt/ache/burn (circle as appropriate)  

Eyes go red/watery? (circle as appropriate)  

Eyes feel dry/itchy? (circle as appropriate)  


LIGHT SENSITIVITY

Are you:

Bothered by bright sunshine?    

Bothered by bright lights?   

Do you:

Squint in bright sunlight?   

Prefer to stay in the shade?   

Prefer to wear sunglasses/hat? (circle as appropriate)   

Eyes need to adjust going from dark to light places?   

Are You:

Bothered by: glare in the environment?   

Bothered by: fluorescent lighting?   

Bothered by: glare on the white page when reading?   

Bothered by: glare/brightness of computer screens?    

Bothered by: bright colours?   

Bothered by: stripes/polka dots/patterns?   

Bothered by: glare when driving   

Please write/type any other relevant information here:

All the questions in the Irlen Self Test® are intended to be answered Yes/No.

There is an option at the end to add additional information if you consider it relevant.

Thank You

Kelly Newbold

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