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Home » Vision Quiz

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
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Our Office

Phone: (704) 822-1574
Email: Sightwork@sightwork.com.
(Do not send personal health information by email.)

7547 Waterside Loop Rd., Suite C
Denver, NC 28037

Monday:8:00 AM - 5:30 PM
Tuesday:8:00 AM - 7:00 PM
Wednesday:8:00 AM - 5:30 PM
Thursday:8:30 AM - 5:30 PM
Friday:8:30 AM - 5:00 PM
Weekends:Closed

Request an Appointment Online or Call Us Now 704-822-1574

SightWork

Phone: (704) 822-1574
Email: Sightwork@sightwork.com.
(Do not send personal health information by email.)

7547 Waterside Loop Rd., Suite C
Denver, NC 28037

Hours

Monday:8:00 AM - 5:30 PM
Tuesday:8:00 AM - 7:00 PM
Wednesday:8:00 AM - 5:30 PM
Thursday:8:30 AM - 5:30 PM
Friday:8:30 AM - 5:00 PM
Weekends:Closed

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