Client details

Record client information before beginning the assessment.

Personal information

Client name

Known as

Date of birth

Occupation

Age

Assessment date

School

Year / Grade

Screener's name

Accompanying adults

Prescription glasses worn during test?

Yes No N/A

Reading difficulties

Section 1 — Part A

Think about what reading for information is like when you get to the point where you want to stop reading. For each item, select Often, Sometimes, Never, or D.K. (don't know).

Question	Often	Sometimes	Never	D.K.

Score

—

Not yet scored

Scoring key

Often = 1 pt
Sometimes = 0.5 pt
Never / D.K. = 0 pt

1–3 = Slight · 4–7 = Moderate
8+ = Severe

Reading discomfort

Section 1 — Part B

Think about what reading for information is like when you get to the point where you want to stop reading. For each item, select Often, Sometimes, Never, or D.K. (don't know).

Question	Often	Sometimes	Never	D.K.

Score

—

Not yet scored

Scoring key

Often = 1 pt
Sometimes = 0.5 pt
Never / D.K. = 0 pt

1–3 = Slight · 4–7 = Moderate
8+ = Severe

Box A

Section 2 — Task 1

N/A — This task was not completed

Question	Yes	No

Questions 7 onwards Say to client Look at the page and keep looking while I ask you the following questions.

Question	Yes	No

Observations / notes

Box B

Section 2 — Task 2

N/A — This task was not completed

Question	Yes	No

Questions 7 onwards Say to client Look at the page and keep looking while I ask you the following questions.

Question	Yes	No

Observations / notes

Pumpkin

Section 2 — Task 3

N/A — This task was not completed

Question	Yes	No

Questions 7 onwards Say to client Look at the page and keep looking while I ask you the following questions.

Question	Yes	No

Observations / notes

Penguin

Section 2 — Task 4

N/A — This task was not completed

Question	Yes	No

Questions 7 onwards Say to client Look at the page and keep looking while I ask you the following questions.

Question	Yes	No

Observations / notes

Dutch / Math / Numbers Page

Section 2 — Task 5

N/A — This task was not completed

Page used

Question	Yes	No

Questions 7 onwards Say to client Look at the page and keep looking while I ask you the following questions.

Question	Yes	No

Observations / notes

Musical Lines

Section 2 — Task 6

N/A — This task was not completed

Column 2

Question	Yes	No

Columns 1 and 3

Question	Yes	No

Head/eyes feeling (0–10)

Discomfort rating (0–10)

Observations / notes

Span of Recognition

Section 2 — Other tasks

N/A — This task was not completed

Instructions

Show the client the Span of Recognition card.
Record the number of circles missed, boxes missed, and whether the star was identified.
Circle the number on a scale of 0–10 to score discomfort.
Circle the result number on the Profile Sheet.

Circles missed

Boxes missed

Star identified?

Discomfort score (0–10)

Total score

Observations / notes

Pointing Task

Section 2 — Other tasks

N/A — This task was not completed

Instructions — With overlay

Place the overlay on the pointing task card.
Time the client on three separate runs.
Record each time in seconds.
Calculate the average (Total A ÷ 3).

A — With overlay

Run 1 (seconds)

Run 2 (seconds)

Run 3 (seconds)

Total A

Average A (seconds)

Instructions — Without overlay

Remove the overlay.
Time the client on three separate runs.
Record each time in seconds.
Calculate the average (Total B ÷ 3).
Subtract Average B from Average A — circle this on the Profile Sheet.

B — Without overlay

Run 1 (seconds)

Run 2 (seconds)

Run 3 (seconds)

Total B

Average B (seconds)

Score (Avg A - Avg B)

—

Circle on Profile Sheet

Observations / notes

Section 3 — Overlays & Distortions

Record overlay colours selected and distortions reported with and without overlay.

Client overlay colours

Overlay 1

Overlay 2

Glare type

Parent overlay colours

Overlay 1

Overlay 2

Glare type

Distortions reported

Select all distortions the client reports.

Amount of improvement with overlay

For each symptom, circle the amount of improvement seen when using the overlay.

Symptom	N/A	Slight	Moderate	Considerable

Client details

Reading difficulties

Reading discomfort

Box A

Box B

Pumpkin

Penguin

Dutch / Math / Numbers Page

Musical Lines

Span of Recognition

Instructions

Pointing Task

Instructions — With overlay

Instructions — Without overlay

Section 3 — Overlays & Distortions

Summary & Download

Location

Email

Phone

Social media