Please check the column that best represents the occurrence of each symptom. Blur when looking at near0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Double vision0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Headaches with near work0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Words run together when reading0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Burning, itchy, watery eyes0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Falls asleep reading0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Sees worse at the end of the day0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Skips/repeats lines when reading0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Dizziness/nausea with near work0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Head tilt/closing one eye when reading0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Difficulty copying from the chalkboard0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Avoids near work/reading0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Omits small words when reading0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Writes uphill/downhill0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Misaligns digits/columns of numbers0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Reading comprehension down0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Poor/inconsistent in sports0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Holds reading too close0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Trouble keeping attention on reading0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Difficulty completing assignments on time0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Always says "I can't" before trying0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Avoids sports/games0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Poor hand-eye (poor handwriting)0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Does not judge distance accurately0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Clumsy, knocks things over0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Does not use their time well0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Does not make change well0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Loses belongings/things0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Car/motion sickness0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Forgetful/poor memory0 - Never1 - Seldom2 - Occasionally3 - Frequently4 - Often Your Name: Your Email Address: Your Telephone Number: Share This Article Share on FacebookShare on Facebook TweetShare on Twitter Pin itShare on Pinterest
