Checklist

Your Symptoms - check the box for how often you or your child have these problems

If total score is more than 20, Your vision or your child’s vision and binocularity need to be checked

Score: 0

never
0
seldom
1
occasionally
2
frequently
3
always
4
Blur at near, such as in reading, over time
Double vision, seeing two instead of one
Headaches with near work such as reading
Words run together when reading
Itching, burning, watery eyes
Fall asleep while reading
See worse, blurrier at end of the day
Skip or repeat lines when reading
Dizzy or nausea with near work
Tilt head or close an eye when reading
Difficulty copying from board in school
Avoid near work and reading
Misses the small words reading
Writes uphill or downhill
Trouble aligning digits or columns of numbers
Poor reading comprehension
Poor performance or inconsistency in sports
Hold reading too close
Trouble keeping attention on reading
Difficulty completing assignments
Say “I can’t” before trying
Avoid sports and games, especially with balls
Poor eye-hand coordination and/or handwriting
Poor distance judgment
Clumsy. Knock things over. Bumps into walls.
Doesn’t use time well.
Doesn’t make change well
Lose things.
Car or motion sickness
Forgetful. Poor memory