Symptoms Check List

  1. SYMPTOMS CHECK LIST
  2. This list of symptoms of visual problems observed at school, work and home will help us understand how you perform visually in your daily activities. Please select one of the choices for each symptom:
  3. Do you have headaches?
  4. Fatique with reading or comprehension drops with time
  5. Confuses similar words or letters
  6. Short attention span
  7. Difficulty keeping place while reading; use fingers as marker
  8. Slow reading or word-by-word reading
  9. Skips or rereads lines;omits words
  10. Avoids reading or close work
  11. Reverses words or letters
  12. Difficulty remembering what has been read
  13. Tilts head to one side or closes or covers one eye
  14. Hold head too close to reading material
  15. Difficulty copying from chalkboard or book
  16. Poor eye-hand coordination, including poor writing
  17. Crossed eyes, turning in or out
  18. Nervousness, irritability or restlessness after sustaining visual concentration
  19. Does your vision get blurry at any time?
  20. Do you ever see objects double?
  21. Do letters and lines "run together" or words "jump"?
  22. Do your eyes feel strained or tired after working on a computer?
  23. (required)
  24. (required)
  25. (valid email required)
 

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