Please provide a brief history of your child's developmental and medical history, citing any unusual difficulties, illnesses or experiences:
Does your child wear glasses? Yes No
When was your child's last eye exam, either by the school or a pediatrician?
Do you know or suspect that your child has food, preservative or dye sensitivities? Any other helpful information concerning food and/or diet? Yes No
What educational difficulties is your child experiencing?
Please describe your child's learning process and educational background
When did you first notice school problems?
What has been done for these difficulties?
Have you been pleased with the progress your child has made with these programs? Please explain.
Yes No
Are there other related problems, such as behavioral, social or disciplinary?
Yes No
Please explain, briefly, the nature of these other problems:
How does your child feel about his school performance?
Is your child's self-image low in regards to school achievement?
Yes No
Is he motivated to do school work?
Yes No
End of Preliminary Assessment Form Part 1
Part II - Symptom Profile Form
Student Name:_________________________________
Fill out this form to rate your child in the abilities listed below. Use the following guide:
5-superior 4-good 3-average 2-below average 1-severe
Attention Span: This is the ability to do close-eye work for at least 20 to 30 minutes. This would include desk work, reading, etc.
5 4 3 2 1
Comprehension: This is the ability to remember what is read, retain information, recall facts and memorize.
5 4 3 2 1
Concentration: This is the ability to stay on task without distraction.
5 4 3 2 1
Reading Skills: This is the ability to read smoothly across a page without choppy, slow, or laborious effort. This includes an ability to read without hesitations, skipping, or miscalling words.
5 4 3 2 1
Handwriting: This is the ability to write neatly, evenly spaced, and with organization.
5 4 3 2 1
Spelling: This is the ability to spell, retain words in long-term memory, and write words without reversals or transposed letters.
5 4 3 2 1
Following Directions: This is the ability to follow written or spoken directions and correctly sequence information.
5 4 3 2 1
Please check (click) each box that your child experiences regardless of frequency of occurrence:
Complains of discomfort in eyes when writing, drawing, cutting, etc. Complains of headaches after reading or writing Tiredness in eyes, excessive blinking, or watery eyes during school Head turns when reading or tilts head when writing Loses place often; needs finger to keep place Displays short attention span when reading Too frequently omits words, word parts, or numbers Rereads or skips lines when reading Misaligns numbers in columns Writes crookedly, poorly spaced Mistakes words with similar beginnings Fails to recognize same word in next sentence Reverses letters and/or words when reading or writing Fails to comprehend what was read Errors in copying from the board, overhead, or a book Slow, choppy, mechanical reading Inability to follow directions Unusually tired or fatigued at the end of the school day Poor spelling ability Avoids reading, homework, or close-eye activity Lack of long-term memory
End of Part II: Symptom Profile Form
Part III: In-Home Evaluation
Student Name ________________________________________
Print this form first, complete all information, and fax completed form to (719) 495-7137
This 4-part screening is designed to enable parents to screen their own child for specific symptoms that hinder reading and learning coordination skills (balance and hopping) imagery eye control (horizontal, vertical, circular), and "aiming-in"
Part A - Coordination Skills
Balance Test
Have the student stand on his right foot, bend over, touch his toes and return to a standing position while continuing to stand on his right foot. Repeat this test with the left foot. Goal: To bend over smoothly on each foot, touch toes and return to a standing position to a count of 5. Watch for: Wobbly performance, falling, performing on one side better than on the other.
Scoring the Balance Test
If the student can bend over, touch his toes, and return to a standing position to the count of 5 on both the left foot and the right foot, indicate a score of "5", below.
If the student executes the test and performs in a slightly wobbly manner on one side (either left or right), score "4", below.
If BOTH left and right foot balance is wobbly, indicate a score of "3", below.
If, in the course of executing this test, the student falls and is unable to return to a standing position without putting down the other foot, or becomes off-balance easily, indicate a score of "2", below.
If the student is extremely poor on both feet, indicate a score of "1", below. 5 4 3 2 1
Hopping Test
Have the student hop on the left foot 5-6 times on each foot, and then stop and continue to stand on that foot. Repeat this test with the right foot. Goal: To hop and stop on each foot without falling. Watch For: Falling, tripping, and an inability to stop and stand on one foot.
Scoring the Hopping Test
If the student can hop and stop while maintaining balance on both the right and the left foot, indicate a score of "5", below.
If the student can hop and stop on one side, but not as well on the other, indicate a score of "4", below.
If the student cannot hop very well on either foot, or falls somewhat or loses his balance, indicate a score of "3", below.
If the student is poor in all of the previous hopping tests and cannot hop but one time before falling, indicate a score of "2", below.
If the student cannot hop at all, indicate a score of "1", below. (For a younger student, use discretion.)
5 4 3 2 1
Part II - Imagery
This evaluation tests a student's ability to visualize letters in the mind, and to maintain a "visual" picture.
Begin this test by dictating a series of letters, such as A B C D, and have the student repeat them forwards and backwards.Then, ask the student if he "sees" them in his mind.
Elementary students should be able to repeat 3-4 different series of letters, forwards and backwards.
Upper students should be able to repeat 5-6 different series of letters, forwards and backwards.
With younger students, begin with a series of two letters, and progress upwards. Goal: To be able to visualize letters in the mind and repeat them forwards and backwards and maintain a visual picture. Watch for: Frustration, missing letters, forgetting, or an inability to repeat a letter series backwards.
Scoring the Imagery Test
If the student can repeat a series of at least 4 letters, forwards and backwards, indicate a score of "5", below.
If the student can repeat a series of 3 letters, forwards and backwards, indicate a score of "4", below.
If the student successfully repeats the series forwards, but experiences difficulty repeating the same series backwards, indicate a score of "3", below.
If the student struggles with processing a series of less than 3 letters, or can repeat the series only forwards, indicate a score of "2", below.
If the student experiences obvious difficulty in repeating 2-letter series, indicate a score of "1", below.
5 4 3 2 1
Part IV - Eye Control
Have the student perform the following eye control tests without his glasses.
Horizontal Tracking
Using a pencil as a wand (eraser end towards student!), make a smooth, eye-level horizontal sweep across the visual field of the student from left to right and back several times.
Have the student visually track the pencil eraser as you move it back and forth.
Tip: Hold the pencil such that the eraser is about six inches from the student's nose while conducting this test.
Making a smooth motion and watch the student's eye's. Do this several times , and then ask a simple question such as, "How do you spell red?", or "When is your birthday?". Goal: To smoothly track across and answer simple questions at the same time. Watch for: Corrective movements, jerkiness, eyes not tracking together, releasing focus on pencil eraser to look at instructor - especially when questions are asked.
Scoring the Horizontal Tracking Test
If the student can follow smoothly across and answer questions, indicate a score of "5", below.
If the student can follow smoothly across, but starts to jerk or gets off-focus a little when asked a question, indicate a score of "4", below.
If the student's eyes become jerky while trying to follow, or he releases and looks at you, indicate a score of "3", below.
If the student cannot follow well at all without getting of target, or his eyes jerk or he releases many times, hesitates, or stares at you, indicate a score of "2", below.
If the student cannot follow at all, indicate a score of "1", below
5 4 3 2 1
Vertical Tracking
Repeat the test immediately above, making smooth vertical movements up and down with the pencil.
Scoring the Vertical Tracking Test
If the student can follow smoothly up and down and answer questions, indicate a score of "5", below.
If the student can follow smoothly up and down, but starts to jerk or gets off-focus a little when asked a question, indicate a score of "4", below.
If the student's eyes become jerky while trying to follow, or he releases and looks at you, indicate a score of "3", below.
If the student cannot follow well at all without getting of target, or his eyes jerk or he releases many times, hesitates, or stares at you, indicate a score of "2", below.
If the student cannot follow at all, indicate a score of "1", below.
5 4 3 2 1
Circular Tracking
This is the same test as the two immediately above, except you are making circles instead of horizontal or vertical motions with the pencil. Have the student cover one eye and track the circular motion slowly with one eye at a time. (Take caution not to make the circular motion out of the students viewing range, but make the circular motion large enough to have the student stretch the eye and go around.) Try some movements clockwise as well as counter-clockwise.
Scoring the Circular Tracking Test
Same instructions as above.
5 4 3 2 1
Circular Tracking with Questions
Same as above. Goal: To be able to move the eyes together in a circular motion smoothly and answer simple questions. Watch for: Jerkiness, getting off point, releasing to look at you, and any other movements other than smooth.
Scoring the Circular Tracking with Questions Test
Same instructions as above.
5 4 3 2 1
Aiming-In Test
Hold the pencil wan about 16 inches out as the student attempts to follow in with his eyes towards his nose. Move the end of the pencil slowly towards the student's eyes and observe the eyes. Can the student follow in with you to his nose, or close to it? Do the two eyes follow in together, or does one eye follow independent of the other.
Goal: To be able to follow the end of the pencil into the nose at least within 2 inches, and back out again, with eyes following in together, without jerkiness, strain, or watering.
Watch for: Jerkiness, eyes unable to come in, eyes spreading at a certain distance, or one eye going out. (Certain students will report that they will see double images of the pencil wand at a certain distance. This is quite normal, and means the student is unable to aim the eyes together. It is important to record the distance the students reports he is seeing double images.)
Scoring the Aiming-In Test
If the student can follow-in smoothly and back out smoothly within an inch or two from the nose, indicate a score of "5", below.
If the student follows-in, but with effort, fatigue, watery eyes, or strain, indicate a score of "4", below.
If the student backs away as you come closer, or begins to see double, or sees double after following-in about 3-4 inches from the nose, indicate a score of "3", below.
If the student begins to see double within about 4-5 inches form the nose, or has a hard time turning his eyes inward, indicate a score of "2", below.
If the student is unable to follow-in without experiencing obvious strain, or one eye turns out quickly, or the student sees double quickly, or one eye doesn't turn in at all with the other eye, indicate a score of "1", below.
Note: This test assumes the student has normal vision with or without corrective lens. If the student has had eye surgery, or is cross-eyed, or some other difficulty, he won't score on this test. Other students have one eye that turns out, or suppresses an eye (i.e., one eye 'turns-off', and doesn't see at all. In these cases, our program will be of little value.
If the student wears glasses, have him perform the tests without his glasses.
