Client Observation Form page 1

Irlen Diagnostic & EEG Biofeedback

25A Mabelle Ave.
Medford, MA 02155
781-396-3321
Fax-781-396-3010

Irlen Institute
5380 WILAGE ROAD LONG BEACH, CA 90808 (562) 496-2550 FAX (562) 429-8699

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CLIENT OBSERVATION FORM FOR IRLEN SYNDROME

Please complete and bring to your appointment. Please print.

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CHARACTERISTICS Please Circle Answer
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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	?

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Types of reading difficulties:

Skip words or lines	Yes	No	?
Repeat or reread 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	?