Vision Quiz 30 Question Predictive Checklist Oculo-motor and Perceptual Name* First Last Email:* Phone Number:*Please answer each question as it applies to the patient.Blur when looking at near?*NeverSeldomOccasionalFrequentlyAlwaysDouble vision, doubled or overlapping words on page?*NeverSeldomOccasionalFrequentlyAlwaysHeadaches while or after doing near vision work?*NeverSeldomOccasionalFrequentlyAlwaysWords appear to run together when reading?*NeverSeldomOccasionalFrequentlyAlwaysBurning, itching, or watery eyes?*NeverSeldomOccasionalFrequentlyAlwaysFalls asleep when reading?*NeverSeldomOccasionalFrequentlyAlwaysSeeing and visual work is worse at the end of the day?*NeverSeldomOccasionalFrequentlyAlwaysSkips or repeats lines while reading?*NeverSeldomOccasionalFrequentlyAlwaysDizziness or Nausea when doing near work?*NeverSeldomOccasionalFrequentlyAlwaysHead tilts or one eye is closed or covered while reading?*NeverSeldomOccasionalFrequentlyAlwaysDifficulty copying from the chalkboard?*NeverSeldomOccasionalFrequentlyAlwaysAvoids doing near vision work such as reading?*NeverSeldomOccasionalFrequentlyAlwaysOmits (drops out) small words while reading?*NeverSeldomOccasionalFrequentlyAlwaysWrites up or down hill?*NeverSeldomOccasionalFrequentlyAlwaysMisaligns digits or columns on numbers?*NeverSeldomOccasionalFrequentlyAlwaysReading comprehension low, or declines as day wears on?*NeverSeldomOccasionalFrequentlyAlwaysPoor, inconsistent performance in sports?*NeverSeldomOccasionalFrequentlyAlwaysHolds books too close, leans too close to computer screen?*NeverSeldomOccasionalFrequentlyAlwaysTrouble keeping attention centered on reading?*NeverSeldomOccasionalFrequentlyAlwaysDifficulty completing assignments on time?*NeverSeldomOccasionalFrequentlyAlwaysFirst response is “I can’t” before trying?*NeverSeldomOccasionalFrequentlyAlwaysAvoids sports or games?*NeverSeldomOccasionalFrequentlyAlwaysPoor hand/eye coordination, such as poor handwriting?*NeverSeldomOccasionalFrequentlyAlwaysDoes not judge distances accurately?*NeverSeldomOccasionalFrequentlyAlwaysClumsy, accident prone, knocks things over?*NeverSeldomOccasionalFrequentlyAlwaysDoes not use or plan his/her time well?*NeverSeldomOccasionalFrequentlyAlwaysDoes not count or make change well?*NeverSeldomOccasionalFrequentlyAlwaysLoses belongings and things?*NeverSeldomOccasionalFrequentlyAlwaysCar or motion sickness?*NeverSeldomOccasionalFrequentlyAlwaysForgetful, poor memory?*NeverSeldomOccasionalFrequentlyAlwaysNumber
