Please check the column that best represents the occurrence of each symptom.

Blur when looking at near
Double vision
Headaches with near work
Words run together when reading
Burning, itchy, watery eyes
Falls asleep reading
Sees worse at the end of the day
Skips/repeats lines when reading
Dizziness/nausea with near work
Head tilt/closing one eye when reading
Difficulty copying from the chalkboard
Avoids near work/reading
Omits small words when reading
Writes uphill/downhill
Misaligns digits/columns of numbers
Reading comprehension down
Poor/inconsistent in sports
Holds reading too close
Trouble keeping attention on reading
Difficulty completing assignments on time
Always says "I can't" before trying
Avoids sports/games
Poor hand-eye (poor handwriting)
Does not judge distance accurately
Clumsy, knocks things over
Does not use their time well
Does not make change well
Loses belongings/things
Car/motion sickness
Forgetful/poor memory
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