Visual Symptoms Checklist After you consider each question, mark the column that applies to the person you are assessing.Blur when looking at near NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Double vision, doubled or overlapping words on page NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Headaches while or after doing near vision work NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Words appear to run together when reading NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Burning, itching or watery eyes NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Gets tired/sleepy when reading NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Seeing and visual work is worse at the end of the day NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Skips or repeats lines while reading NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Dizziness or nausea when doing near work NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Head tilts or one eye is closed or covered while reading NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Difficulty copying from the chalkboard NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Avoids doing near vision work such as reading NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Omits (drops out) small words while reading NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Writes up or down hill NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Misaligns digits or columns of numbers NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Reading comprehension low, or declines as day wears on NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Poor, inconsistent performance in sports NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Holds books too close, leans too close to computer screen NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Trouble keeping attention centered on reading NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Difficulty completing assignments on time NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS First response is “I can’t” before trying NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Avoids sports and games NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Poor hand/eye coordination, such as poor handwriting NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Does not judge distances accurately NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Clumsy, accident prone, knocks things over NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Does not use or plan his/her time well NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Difficulty with money concepts, making change NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Loses belongings and things NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Car or motion sickness NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS Forgetful, poor memory NEVER SELDOM OCCASIONAL FREQUENTLY ALWAYS TOTAL SCOREA score of 20 or more indicates a need for a vision therapy consult Δ