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Symptoms Check List

Symptoms Check List

SYMPTOMS CHECK LIST
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:
Do you have headaches?
Often Sometimes Never
Fatique with reading or comprehension drops with time
Often Sometimes Never
Confuses similar words or letters
Often Sometimes Never
Short attention span
Often Sometimes Never
Difficulty keeping place while reading; use fingers as marker
Often Sometimes Never
Slow reading or word-by-word reading
Often Sometimes Never
Skips or rereads lines;omits words
Often Sometimes Never
Avoids reading or close work
Often Sometimes Never
Reverses words or letters
Often Sometimes Never
Difficulty remembering what has been read
Often Sometimes Never
Tilts head to one side or closes or covers one eye
Often Sometimes Never
Hold head too close to reading material
Often Sometimes Never
Difficulty copying from chalkboard or book
Often Sometimes Never
Poor eye-hand coordination, including poor writing
Often Sometimes Never
Crossed eyes, turning in or out
Often Sometimes Never
Nervousness, irritability or restlessness after sustaining visual concentration
Often Sometimes Never
Does your vision get blurry at any time?
Often Sometimes Never
Do you ever see objects double?
Often Sometimes Never
Do letters and lines "run together" or words "jump"?
Often Sometimes Never
Do your eyes feel strained or tired after working on a computer?
Often Sometimes Never
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