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Short Irlen Self Test
Please fill out this form. Parents to complete the form in cooperation with your child. Answer the following questions.
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* Indicates required question
Name (Parent or adult)
*
Your answer
Name (Child)
Your answer
Age (Child)
*
Your answer
Contact no. :
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Your answer
Email:
*
Your answer
Please kindly state where you get this piece of info from:
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Your answer
1. Do you skip words or lines when reading?
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Yes
No
2. Do you reread lines?
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Yes
No
3.
Do you lose your place?
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Yes
No
4. Are you easily distracted when reading?
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Yes
No
5.
Do you need to take breaks often?
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Yes
No
6.
Do you find it harder to read the longer you read?
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Yes
No
7.
Do you get headaches when you read?
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Yes
No
8.
Do your eyes get red and watery?
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Yes
No
9.
Does reading make you tired?
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Yes
No
10.
Do you blink or squint?
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Yes
No
11.
Do you prefer to read in dim light?
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Yes
No
12.
Do you read close to the page?
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Yes
No
13.
Do you use your finger or other markers?
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Yes
No
14.
Do you get restless, active, or fidgety when reading?
*
Yes
No
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