Insight - Approaches for Visual Perceptual Difficulties
Report Required For:	Home School Combined Report Two Separate Reports
Child's forename:
Child's surname:
Gender:	Male Female
Date of Birth:
Reference Number:
Does the child walk independently?	Yes, all the time Yes, but needs assistance at times No, uses a wheel chair
Question Inventory
Does your child trip or bump into things on the floor?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to walk down stairs?	Never Rarely Sometimes Often Always N/A
Does your child trip or seem not to notice when pavements go up or down?	Never Rarely Sometimes Often Always N/A
Does your child seem to 'get stuck' at the top of a slide or hill?	Never Rarely Sometimes Often Always N/A
Does your child look down when they cross floor boundaries, for example where lino meets carpet?	Never Rarely Sometimes Often Always N/A
Does your child leave food on their plate? If so, is this on the near or far side?	Never Rarely Sometimes Often Always N/A
Does your child leave food on their plate? If so, is this on the left or right side?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty stepping into the bath, apart from any problems with balance?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to find the beginning of a line or the next word when reading, or miss pictures or words on one side of a page (left /right)?	Never Rarely Sometimes Often Always N/A
Does your child move out in front of traffic (coming from left/ right / both)?	Never Rarely Sometimes Often Always N/A
Does your child bump into door frames or partly open doors (left/right/both)?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty seeing things from a moving vehicle?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot things that are moving quickly, such as children or small animals?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to see moving water i.e. to fill a cup?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to follow a cursor on the computer screen?	Never Rarely Sometimes Often Always N/A
Does your child avoid watching fast moving TV programmes, and prefer to watch slow moving TV programmes?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to catch a ball?	Never Rarely Sometimes Often Always N/A
When walking, does your child hold onto your clothes, tugging down?	Never Rarely Sometimes Often Always N/A
Does your child find uneven ground hard to walk over?	Never Rarely Sometimes Often Always N/A
Does your child bump into low furniture, for example a small table?	Never Rarely Sometimes Often Always N/A
Does your child get angry if furniture is moved?	Never Rarely Sometimes Often Always N/A
Does your child explore floor boundaries (for example, where lino meets a carpet) with their foot before crossing it or find floor boundaries difficult to cross?	Never Rarely Sometimes Often Always N/A
Does your child reach incorrectly for objects (i.e. reaches beyond or around the object or when picking it up, grasp incorrectly, missing or knocking the object over)?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot something pointed out in the distance?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot a close friend or relative standing in a group?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty playing team games with a lot of players, especially if there are a lot of players and everyone is moving?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty finding an item on supermarket or cupboard shelf e.g. finding the cereal or biscuits?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot an item of clothing in a pile of clothes?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot the toy they want in a full toy box, shoe in a box of shoes etc?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot objects when they are on a similar background, such as a white tee shirt on a white sheet?	Never Rarely Sometimes Often Always N/A
Does your child get lost in places where there is a lot to see, e.g. in a crowded shopping centre?	Never Rarely Sometimes Often Always N/A
Does your child find copying words or drawings time consuming and difficult?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty reading crowded text on paper or on a computer screen, but can cope better if some of the text is covered or taken away?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot letters on a keyboard but knows the alphabet?	Never Rarely Sometimes Often Always N/A
Does your child sit closer to the television than about 30 cm?	Never Rarely Sometimes Often Always N/A
Does your child find it difficult to keep to task for more than 5 minutes, or after being distracted do they find it difficult to get back to what they were doing?	Never Rarely Sometimes Often Always N/A
Does your child react angrily when other children cause distractions?	Never Rarely Sometimes Often Always N/A
Does your child bump into things when they are walking and talking at the same time?	Never Rarely Sometimes Often Always N/A
Does your child miss objects that are obvious to you because they are different from their background and seem to 'pop out' e.g. a bright ball in the grass?	Never Rarely Sometimes Often Always N/A
Does your child get upset in busy places, such as supermarkets or shopping centres?	Never Rarely Sometimes Often Always N/A
Does your child find it difficult to recognise close relatives in real life?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to recognise close relatives from photographs?	Never Rarely Sometimes Often Always N/A
Does you child mistakenly identify strangers as people known to them?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty understanding the look on your face?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty naming common colours?	Never Rarely Sometimes Often Always N/A
Does your child have difficulty naming basic shapes such as squares, triangles and circles?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to recognising well known objects such as the family car, classroom door?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to find their way around a well known environment, for example school?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to recognise an object if it is partially hidden or viewed from an unusual angle (such as a shoe under the bed with only the toe showing)?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to spot which shoe is right and which shoe is left?	Never Rarely Sometimes Often Always N/A
Does your child find it hard to recognise people, or words, or objects if they are changed in any way, for example font of text, hairstyle?	Never Rarely Sometimes Often Always N/A
Does your child find it difficult to identify where sound is coming from, for example if they shout for you in the house do you have to clearly tell them which room you are in, as they are unable to work out where you are from your voice alone?	Never Rarely Sometimes Often Always N/A