Use this symptom checklist to determine if you or your child may have a visual skills deficiency. Answer the questions below by ranking your symptoms from 0 to 4. The scoring is as follows: 0 — never occurs 1 — seldom occurs 2 — occasionally occurs 3 — frequently occurs 4 — always occursBlur when looking at near 0 1 2 3 4 Double vision 0 1 2 3 4 Headaches with near work 0 1 2 3 4 Words run together or move when reading 0 1 2 3 4 Burning, itchy, watery eyes 0 1 2 3 4 Falls asleep reading 0 1 2 3 4 Sees worse at the end of the day 0 1 2 3 4 Skips/repeats lines when reading 0 1 2 3 4 Dizziness / nausea with near work 0 1 2 3 4 Head tilt / closing one eye when reading 0 1 2 3 4 Difficulty copying from board 0 1 2 3 4 Avoids near work / reading 0 1 2 3 4 Omits small words when reading 0 1 2 3 4 Misaligns digits / columns of numbers 0 1 2 3 4 Reading comprehension poor 0 1 2 3 4 Poor or inconsistent performance in sports 0 1 2 3 4 Holds books too close while reading 0 1 2 3 4 Trouble keeping attention while reading 0 1 2 3 4 Difficulty completing assignments on time 0 1 2 3 4 Always says, “I can’t,” before trying 0 1 2 3 4 Avoids sports / games 0 1 2 3 4 Poor hand-eye coordination (poor handwriting) 0 1 2 3 4 Does not judge distance accurately 0 1 2 3 4 Clumsy, knocks things over 0 1 2 3 4 Does not use his/her time well 0 1 2 3 4 Does not accept change well 0 1 2 3 4 Loses belongings and things 0 1 2 3 4 Car/motion sickness 0 1 2 3 4 Forgetful/poor memory 0 1 2 3 4 * Quality of Life checklist courtesy of College of Optometrists in Vision Development (COVD) What Our Patients Are Saying Leave a Review
