Self-Test For Irlen Syndrome

Name*

First Last

Email*

Age (2 digits)*

Grade*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

NOTE: YOUR EXPERIENCES CAN BE IN THE PAST, WHEN IN SCHOOL, AS WELL AS THE PRESENT.

CHARACTERISTICS

Are you light sensitive?

Bothered by sunlight

Yes
No

Bothered by glare

Yes
No

Do you frequently wear sunglasses?

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 / stomachache 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

Shade the page with your hand or body

Yes
No

Self-Test For Irlen Syndrome

Irlen Self-Test

Step 1 of 5

CHARACTERISTICS

Are you light sensitive?

Types of reading difficulties

While reading or using a computer, do you:

Do you feel strain, fatigue, tired, or have headaches when:

Handwriting

Attention/Concentration

Copying:

Composition/Essay Writing:

Mathematics

Music:

Depth Perception

Sports Performance:

Driving:

Fatigue While In A Car

For further information, contact: http://irlen.com/