Client Observation Form page 2

Client Observation Form For Irlen Syndrome - Page 2

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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	?

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Do you feel strain, fatigue, 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, etc.	Yes	No	?
Working under bright or fluorescent lights	Yes	No	?

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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 scantron answer sheets	Yes	No	?
Leave out words, letters, or punctuation marks	Yes	No	?

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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	?