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?* Never Seldom Occasional Frequently Always Double vision, doubled or overlapping words on page?* Never Seldom Occasional Frequently Always Headaches while or after doing near vision work?* Never Seldom Occasional Frequently Always Words appear to run together when reading?* Never Seldom Occasional Frequently Always Burning, itching, or watery eyes?* Never Seldom Occasional Frequently Always Falls asleep when reading?* Never Seldom Occasional Frequently Always Seeing and visual work is worse at the end of the day?* Never Seldom Occasional Frequently Always Skips or repeats lines while reading?* Never Seldom Occasional Frequently Always Dizziness or Nausea when doing near work?* Never Seldom Occasional Frequently Always Head tilts or one eye is closed or covered while reading?* Never Seldom Occasional Frequently Always Difficulty copying from the chalkboard?* Never Seldom Occasional Frequently Always Avoids doing near vision work such as reading?* Never Seldom Occasional Frequently Always Omits (drops out) small words while reading?* Never Seldom Occasional Frequently Always Writes up or down hill?* Never Seldom Occasional Frequently Always Misaligns digits or columns on numbers?* Never Seldom Occasional Frequently Always Reading comprehension low, or declines as day wears on?* Never Seldom Occasional Frequently Always Poor, inconsistent performance in sports?* Never Seldom Occasional Frequently Always Holds books too close, leans too close to computer screen?* Never Seldom Occasional Frequently Always Trouble keeping attention centered on reading?* Never Seldom Occasional Frequently Always Difficulty completing assignments on time?* Never Seldom Occasional Frequently Always First response is “I can’t” before trying?* Never Seldom Occasional Frequently Always Avoids sports or games?* Never Seldom Occasional Frequently Always Poor hand/eye coordination, such as poor handwriting?* Never Seldom Occasional Frequently Always Does not judge distances accurately?* Never Seldom Occasional Frequently Always Clumsy, accident prone, knocks things over?* Never Seldom Occasional Frequently Always Does not use or plan his/her time well?* Never Seldom Occasional Frequently Always Does not count or make change well?* Never Seldom Occasional Frequently Always Loses belongings and things?* Never Seldom Occasional Frequently Always Car or motion sickness?* Never Seldom Occasional Frequently Always Forgetful, poor memory?* Never Seldom Occasional Frequently Always HiddenNumber
