PLEASE COMPLETE ALL questions, and ask the child when appropriate
Please rank each of the following symptoms with a number value 0 -4
0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always
Blurred vision at near
0
1
2
3
4
Misaligns digits in columns of numbers
0
1
2
3
4
Double vision
0
1
2
3
4
Poor handwriting, writing uphill or downhill
0
1
2
3
4
Headaches associated with near work
0
1
2
3
4
Reading comprehension declines over time
0
1
2
3
4
Painful, sore, or watery eyes
0
1
2
3
4
Holds reading material too close
0
1
2
3
4
Gets tired when reading
0
1
2
3
4
Difficulty reading for as long as expected/desired
0
1
2
3
4
Vision worse at the end of the day
0
1
2
3
4
Short attention span
0
1
2
3
4
Words run together when reading or move on the page
0
1
2
3
4
Difficulty completing assignments in reasonable time
0
1
2
3
4
Skipping or repeating lines when reading
0
1
2
3
4
Inconsistent or poor sports performance
0
1
2
3
4
Omitting small words when reading
0
1
2
3
4
Avoiding sports and games
0
1
2
3
4
Avoidance of reading or near work
0
1
2
3
4
Poor sense of space, knocks things over, clumsy
0
1
2
3
4
Dizziness or nausea associated with near work
0
1
2
3
4
Car sickness or motion sickness
0
1
2
3
4
Head tilted or turned
0
1
2
3
4
Closing one eye when reading
0
1
2
3
4
Difficulty copying from chalkboard
0
1
2
3
4
Reversal of letters like b's, d's, p's, and q's
0
1
2
3
4
List any other vision related concerns: