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Online Self Test

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Online Self Test

This section will allow you to fill out our online self test. Please enter your contact details and fill out the questions below.
This should take approximately 5-10 minutes and all data is sent over a secure, encrypted connection.
Please add any further comments or details in the box provided at the bottom.

Once this has been completed, I will be in touch shortly to discuss the next steps:

Name *

First

Last

Email *

Telephone Number

Date of last eye test: *

Depth

Hold onto the railing/wall going up and down the stairs? *

Yes
No

Trip up at the top or bottom of the stairs? *

Yes
No

Sometimes think there is another step but there isn’t? *

Yes
No

Bump into the edges of furniture or doorways by accident? *

Yes
No

When walking with people you tend to walk into them? *

Yes
No

When walking you tend to veer off to one side? *

Yes
No

Found learning to ride a bike difficult because of poor balance? *

Yes
No

Still have difficulty going in a straight line on a bike? *

Yes
No
Not Applicable

Tend to hit the kerb if riding a bike too close to the kerb? *

Yes
No
Not Applicable

Hesitate when using escalators? *

Yes
No

Feel dizzy on heights or ladders? *

Yes
No

Have difficulty catching a ball? *

Yes
No

Clumsy or accident prone? *

Yes
No

Feel dizzy/light headed when walking around normally? *

Yes
No

Having difficulty skipping or jumping? *

Yes
No

Have difficulty with merry-go-round or rides at fairs? *

Yes
No

Drop things easily or knock things over easily? *

Yes
No

Tend to put things too close to the edge of a table or surface? *

Yes
No

Tend to be extra cautious when parking or overtaking cars? *

Yes
No
Not Applicable

Find it difficult to judge the speed of other cars? *

Yes
No
Not Applicable

Find it difficult to drive and take in things around you? *

Yes
No
Not Applicable

Reading Questions

Do you enjoy reading? *

Yes
No

Do you use a marker/finger to keep your place? *

Yes
No

Easily lose your place when reading? *

Yes
No

Skip lines when reading? *

Yes
No

Skip words when reading? *

Yes
No

Re-read lines by mistake? *

Yes
No

Re-read lines for meaning? *

Yes
No

Read for only a short time? *

Yes
No

Do you find reading gets worse with time? *

Yes
No

Do you find that words look different or change after a while? *

Yes
No

Do you shade the page to reduce glare? *

Yes
No

Move closer to the page? *

Yes
No

Move further from the page? *

Yes
No

Do you become restless when reading? *

Yes
No

Do you become easily distracted? *

Yes
No

Need to take frequent breaks? *

Yes
No

Rub eyes? *

Yes
No

Frown or squint? *

Yes
No

Blink frequently? *

Yes
No

Open eyes wide? *

Yes
No

Feel drowsy? *

Yes
No

Feel dizzy? *

Yes
No

Feel nauseous? *

Yes
No

Get a headache? *

Yes
No

Eyes feel tired or strained? *

Yes
No

Eyes hurt/ache/burn ? (Tick as appropriate) *

Hurt
Ache
Burn
Not Applicable

Eyes go red/watery? (Tick as appropriate) *

Red
Watery
Not Applicable

Eyes feel dry/itchy? (Tick as appropriate) *

Dry
Itchy
Not Applicable

Checkboxes

Bothered by: bright sunshine? *

Yes
No

Bothered by: bright lights? *

Yes
No

Squint in bright sunlight? *

Yes
No

Prefer to stay in the shade? *

Yes
No

Prefer to wear sunglasses/hat? (Tick as appropriate) *

Sunglasses
Hat
Not Applicable

Eyes need to adjust going from dark to light places? *

Yes
No

Bothered by: glare in the environment? *

Yes
No

Bothered by: fluorescent lighting? *

Yes
No

Bothered by: glare on the white page when reading? *

Yes
No

Bothered by: glare/brightness of computer screens? *

Yes
No

Bothered by: bright colours? *

Yes
No

Bothered by: glare when driving *

Yes
No
Not Applicable

Bothered by: stripes/polka dots/patterns? *

Yes
No

Any additional thoughts or comments:

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