The
only
clinic offering visceral manipulation and laser therapies within 120 miles of San Angelo!
Home
About
Services Provided
Visceral Manipulation
Functional Neurology
Vagus Nerve Rehab
Primitive Reflex Integration
Instrument Assisted Manual Therapy
IRLEN Syndrome Screening
Senaptec Sensory Station
Dry Needling
FAQ
Contact Us
Fill OUt the Form
IRLEN Self Test
Please fill out the form in its entirety.
Name
Phone
Email
Grade
Age
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
Reading Difficulties
Do you skip words or lines?
Yes
No
Do you repeat or reread lines?
Yes
No
Do you read with breaks?
Yes
No
Do you lose your place?
Yes
No
Do you read in a "stop and go" rhythm?
Yes
No
Do you omit small words?
Yes
No
Do you have poor reading comprehension?
Yes
No
Does reading becomes harder the longer you read?
Yes
No
Do you use your finger or market to help keep your place?
Yes
No
Do you avoid reading?
Yes
No
Do you avoid reading for pleasure?
Yes
No
Do you reread for comprehension?
Yes
No
Do reverse letters and/or numbers?
Yes
No
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
Change position to reduce glare
Yes
No
Close or cover one eye
Yes
No
Move head
Yes
No
Read word by word
Yes
No
Unable to speed read
Yes
No
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, movies, or live stage productions
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, crossword puzzles, woodworking, soldering, etc.
Yes
No
Working under bright or fluorescent lights
Yes
No
Looking at stripes, patterns, bright colors, and high contrast
Yes
No
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
Leave out words, letters, or punctuation marks
Yes
No
Attention/Concentration
Problems concentrating with reading or writing
Yes
No
Easily distracted when reading or writing
Yes
No
Easily distracted when listening
Yes
No
Easily distracted when taking tests
Yes
No
Daydreams in class or at lectures
Yes
No
Problems staying on task
Yes
No
Problems starting tasks
Yes
No
Difficulty with scantron answer sheets
Yes
No
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 or off computer typewriter
Yes
No
Composition/Essay Writing
Disorganized
Yes
No
Problems with punctuation
Yes
No
Problems proofreading
Yes
No
Leave out letters or words
Yes
No
Write without rereading
Yes
No
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 or notes and words together
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
Afraid of heights
Yes
No
Sports Performance
Problems tracking a flying ball like golf, baseball, or tennis
Yes
No
Trouble following the ball when watching sports on TV such as tennis, football or basketball
Yes
No
When watching sports on TV, can you follow the ball but not see anything else
Yes
No
Trouble catching or hitting a ball
Yes
No
Difficulty playing pool
Yes
No
Difficulty hitting the ball when playing baseball or 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
On playground equipment such as rings or bars, was it hard to go from one to the other
Yes
No
Trouble playing games such as volley ball or four square
Yes
No
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 when 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
Fatigue While in a Car
As a passenger, do you become drowsy
Yes
No
When driving, do you become drowsy
Yes
No
Bothered by glare on the chrome on cars
Yes
No
Bothered by glare off the rear window of the car in front of you
Yes
No
Stressful to drive in the rain/snow (glare)
Yes
No
Avoid driving at night
Yes
No
Bothered by headlights and street lights at night
Yes
No
Bothered by tail lights on cars
Yes
No
Bothered by red/green traffic lights
Yes
No
Have night blindness
Yes
No
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Shauna Owens | PT, DPT
Angelo Integrative Therapy
How to find us:
3144 Executive Dr. San Angelo, TX 76904
shaunapt@angelointegrativetherapy.com
(325) 253-5911
