Client Observation Form page 3

Client Observation Form For Irlen Syndrome - Page 3

______________________________________________________________________________________________________

Copying

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 computer or typewriter	Yes	No	?

______________________________________________________________________________________________________

Writing:

______________________________________________________________________________________________________

Mathematics:

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:

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	Yes	No	?
Difficulty interpreting the music notations	Yes	No	?
Little progress in spite of regular practice	Yes	No	?

______________________________________________________________________________________________________

Depth Perception:

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	?
Difficulty getting on or off moving objects	Yes	No	?