Client Observation Form page 4

Client Observation Form For Irlen Syndrome - Page 4

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Driving:

Difficulty parallel parking	Yes	No	?
Do you feel like you will hit the car in front when parking	Yes	No	?
When parking, do you hit the curb or leave too much space	Yes	No	?
Difficulty judging when to turn in front of oncoming traffic	Yes	No	?
Uncertain about making lane changes	Yes	No	?
Extra cautious when making lane changes	Yes	No	?
Are the passengers tense when you make lane changes	Yes	No	?
Do passengers tell you that you tailgate	Yes	No	?
Are you overly cautious, leaving extra room between you and the car ahead	Yes	No	?

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Sports Performance:

As a child, problem catching a small fly ball	Yes	No	?
Trouble following the ball when watching sports on TVsuch as tennis, football or basketball	Yes	No	?
When watching sports on TV, can you follow the ball but not see anything else	Yes	No	?
Difficulty playing pool	Yes	No	?
Difficulty knowing when to hit the ball when playing tennis	Yes	No	?
Trouble learning how to ride a bike	Yes	No	?
Trouble jumping rope? Jump in at the wrong time or jump into the rope	Yes	No	?
Trouble playing games such as volley ball or four square	Yes	No	?
On playground equipment such as rings or bars, was it hard to go from one to the other	Yes	No	?

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Fatigued In A Car

Become drowsy when you are a passenger	Yes	No	?
Become drowsy when driving	Yes	No	?
Bothered by chrome on cars	Yes	No	?
Bothered by glare off the windshield of the car in front of you	Yes	No	?
Bothered by headlights and street lights	Yes	No	?
Avoid driving at night	Yes	No	?
Have night blindness	Yes	No	?

If you answered yes to three or more of these questions in any one of the above sections, then you might be experiencing the effects of a perception problem called Scotopic Sensitivity/Irlen Syndrome.

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