Symptoms Questionnaire

Symptoms Questionnaire

Symptoms Questionnaire

Symptoms Questionnaire


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Double Vision​​​​​​​

Words moving/swimming on a page

Eyes Tired/Sore

Dizziness/motion sickness

Frustrated with school

Bothered by light

Frequent Blinking

Closing/Covering one eye or squints​​​​​​​

Difficulty seeing distant objects

Holds work close or head close to work

Avoids reading or other close work

Tilts head when reading

Tilts head when writing​​​​​​​

Confuses or Reverses letters/words/numbers

Skips, rereads, omits words, loses place​​​​​​​

Vocalizes when reading

Reads slowly​​​​​​​

Uses finger or marker when reading

Poor reading comprehension​​​​​​​

Comprehension decreases over time

Writes/Prints poorly

Eyes tire quickly when reading

Homework takes too long

Frequent erasures

Difficulty copying from board

Difficulty with memory

Remembers better what hears than sees

Responds better orally than written

Performing below potential

Dislikes/avoids near tasks

Short attention span/easily distracted​​​​​​​

Poor large motor coordination

Poor fine motor coordination

Avoids/dislikes Sports

Difficulty hitting a ball

Eye strain/blurry vision while reading/working

Often appears clumsy

Your Score:
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