VisionSource! - North America's Premier Network of Private Practice Optometrists
North America's Premier Network of Private Practice Optometrists

2 locations to serve

your eyecare needs.

University Place Office
Yelm Office


 

 


 

Symptoms Checklist

 

Please check the column which best represents the occurrence of each symptom:

 

 

Never

Seldom

Occasional

Frequently

Always

Headaches

0

1

2

3

4

Blurry vision at near or far

0

1

2

3

4

Double vision

0

1

2

3

4

Excessive blinking, squinting or rubbing   eyes

0

1

2

3

4

Sensitive to light

0

1

2

3

4

Burn, itch, watery eyes

0

1

2

3

4

Does not judge distances accurately

0

1

2

3

4

Car/motion sickness

0

1

2

3

4

Sees worse at the end of the day

0

1

2

3

4

Loses belongings/things

0

1

2

3

4

Forgetful/poor memory

0

1

2

3

4

Poor / inconsistent / avoids sports

0

1

2

3

4

Clumsy / Knocks thing over

0

1

2

3

4

Difficulty copying from chalkboard/overhead

0

1

2

3

4

Difficulty completing assignments on time

0

1

2

3

4

Does not use his/her time well

0

1

2

3

4

Writes up/down hill

0

1

2

3

4

Poor eye/hand (poor handwriting)

0

1

2

3

4

Misaligns digits/columns of numbers

0

1

2

3

4

Always says “I can’t” before trying

0

1

2

3

4

Holds reading too close

0

1

2

3

4

Loses their place while reading

0

1

2

3

4

Moves head or lips while reading

0

1

2

3

4

Reverses words or letters while reading

0

1

2

3

4

Repeats words or lines while reading

0

1

2

3

4

Omits small words while reading

0

1

2

3

4

Closes or covers one eye when reading

0

1

2

3

4

Words run together when reading

0

1

2

3

4

Falls asleep when reading

0

1

2

3

4

Tilts head or closes one eye

0

1

2

3

4

Avoids near work/reading

0

1

2

3

4

Reading comprehension down

0

1

2

3

4

Trouble keeping attention on close work

0

1

2

3

4

TOTAL

 

 

 

 

 

Add up all the numbers.  If score is over 20, there might be a learning related vision problem.  If over 25, it is probable that there is a learning related vision problem.

 

Other comments: