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SYMPTOMS CHECKLIST

Do you have, or have you observed any of the following symptoms with your students or yourself and / or have they reported any of them to you? Please check the box next to the symptoms that occur frequently or occasionally. You will see your score and our recommendation at the bottom. Please print and bring to your next appointment.

		Score: 0
		Skip lines while reading or copying
		Lose your place while reading or copying
		Skip words while reading or copying
		Substitute words while reading or copying
		Reread words or lines
		Reverse letters, numbers or words
		Use a finger or marker to keep place while reading/writing
		Read very slowly
		Poor reading comprehension (unless read to)
		Difficulty remembering what has been read
		Hold your head too close when reading/writing (within 7-8")
		Squint, close or cover one eye while reading
		Unusual posture/head tilt when reading/writing
		Headaches following intense reading/computer work
		Eyes hurt or feel tired after completing a visual task
		Feel unusually tired after completing a visual task
		Have double vision
		Vision blurs at distance when looking up from near work
		Have crooked or poorly spaced writing
		Notice that print seems to move or go in and out of focus
		Have poor spelling skills
		Notice that letters or lines "run together" or words "jump" when reading
		Misalign letters or numbers
		Make errors when copying
		Have difficulty tracking moving objects
		Unusual clumsiness, poor concentration
		Have difficulty with sports involving good hand-eye coordination
		Eye that turns in or out
		See more clearly with one eye than the other
		Feel sleepy while reading
		Dislike tasks requiring sustained concentration
		Avoid near tasks such as reading
		Confuse right and left directions
		Become restless when working at a desk
		Tend to lose awareness of surroundings when concentrating
		Must "feel" things to see them
		Carsickness
		Unusual blinking
		Unusual eye rubbing
		Dry eyes
		Watery eyes
		Red eyes
		Eyes bothered by light
Score: 0
Criteria: 15-20 points total = Possible functional vision problems 21-30 points total = Probable functional vision problems Over 30 points total = Definite functional vision problems 15+ total points = Consultation with our office advised