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  About
   Steve Shapiro
  
Colorado Springs, CO
  
Founder & Director

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   Katheryn Mitchell
  
Houston, TX
   Educ. Therapist &
   
Consultant

 

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NEW TOLL FREE:  (888) 556-0230

DISCLAIMER

Please read the following carefully:

 Mr. Shapiro is not a licensed optometrist or opthalmologist.  He does not diagnose or treat the presence of abnormal conditions of the eye and its appendages, or the accommodative and refractive conditions of the eye:  or prescribe visual training and/ or the use of scientific instruments to train the visual system.  He is not licensed in the state of Colorado to do so.  You should consult with and follow the instructions of an optometrist or opthalmologist when using visual training procedures.


 

Part III:  In-Home Evaluation

Student Name ____________________________

Print this form first, complete all information,
and fax completed form to (719) 495-7137

E-Mail:  learningconnection@peoplepc.com

 

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.

5          4         3         2         1

END OF ENTIRE PROFILE: READY TO SEND OR FAX TO:

THE LEARNING CONNECTION:  (719)495-7137

 

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