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Check the column which best represents the occurrence of each symptom

Category A Symptoms

Blur when looking at near

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Headaches with near work

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Sees worse at end of the day

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Difficulty copying from the Chalkboard

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Avoids near work/reading

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Holds head too close to the page

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Category B Symptoms

Has double vision

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Words run together while reading

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Eyes burn, itch, or seem watery

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Falls asleep while reading

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Closes one eye or tilts head while reading

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Category OR Symptoms

Dizzy or nauseous with near work

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Writes up or down hill

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Poor/inconsistent in sports

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Avoids sports/games

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Clumsy/knocks things over

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Car/motion sickness

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Poor hand-eye coordination/poor handwriting

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Category OM Symptoms

Skips or repeats lines when reading

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Misaligns digits/columns of numbers

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Category P Symptoms

Reading comprehension is poor

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Trouble keeping attention on reading

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Says “I can’t” before trying

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Does not use his/her time well

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Does not make change well with money

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Loses belongings/things

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Forgetful/poor memory

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Category ALL Symptoms

Difficulty completing assignments on time

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

Does not judge distance accurately

Never
 
Seldom
 
Ocass.
 
Freq
 
Always
 

TOTAL Score 0


 
  
Correcting and improving binocular, oculomotor, visual processing/perceptual and brain injury disorders.© 2017 Advanced Vision Therapy, All Rights Reserved.
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