Often it is difficult to know if your or your child's vision is not performing in the most efficient way. So we have provided you with a way to check your or your child's symptoms to see if they are visually related. Click on the appropriate checklist below to see if vision is the problem.

                   
 

To find out if your child has a learning related vision problem complete the Child Vision Checklist below or click on the printable version. If the score is above 25 your child needs to see a developmental optometrist for a comprehensive vision evaluation.
 

 

Learning Related Vision Problem Symptom Checklist
How often does your child experience or have the following symptoms: Never Seldom
(1-2 x/mo)		 Occasionally
(3-5 x/mo)		 Frequently
(2-3 x/wk)		 Always
(4-5 x/wk
1. Blur when looking at near?

2. Double vision, doubled or overlapping words on a page?

3. Headaches while doing near work or reading?

4. Words appear to run together when reading?

5. Eyes burn, itch, or water?

6. Falling asleep when reading?

7. Seeing and visual work are worse at the end of the day?

8. Skips or repeats lines/words while reading?

9. Dizziness or nausea when doing near work?

10. Head tilts or one eye is closed or covered while reading?

11. Difficulty copying from the chalkboard or smartboard?

12. Avoids doing near vision work such as reading?

13. Omits (drops out) small words while reading?

14. Writes up or down hill?

15. Misaligns digits or columns of numbers?

16. Low reading comprehension or comprehension that decreases during the day?

17. Poor, inconsistent performance in sports?

18. Holds books too close or leans too close to the computer screen?

19. Trouble keeping attention centered on reading?

20. Difficulty completing assignments on time or in a timely fashion?

21. Says "I can't" before even trying?

22. Avoids sports or games?

23. Poor hand/eye coordination such as poor handwriting?

24. Judges distances inaccurately? (i.e. knocks things over)

25. Clumsy or accident prone?

26. Does not use or plan his/her time well?

27. Difficulty counting or making change?

28. Loses his/her belongings or things?

29. Car/motion sickness?

30. Forgetful or have poor memory?

   Please provide the following contact information so we can send you your child's vision quiz results:

First Name
Last Name
Phone ex. 405-444-5555
E-mail
Who does this describe?

         
 
 

To find out if you have a vision problem that interferes with your daily activities complete the Adult/Brain Injury Vision Checklist below or click on the printable version. If the score is above 25 you need to see a rehabilitation optometrist for a comprehensive vision evaluation.
 

Adult                         Brain Injury

 

Vision Problem Symptom Checklist
How often do you experience or have the following symptoms: Never Seldom
(1-2 x/mo)		 Occasionally
(3-4 x/mo)		 Frequently
(2-3 x/wk)		 Always
(4-5 x/wk)
1. Blur when looking at near
2. Double vision:
3. Headaches with near work
4. Words run together when reading
5. Burning, itchy, watery eyes
6. Falling asleep when reading
7. Vision is worse at the end of the day
8. Skipping/repeating lines when reading
9. Dizzy/Nausea with near work
10. Head tilt/closing one eye when reading
11. Difficulty focusing/changing focus
12. Avoid near work/reading/writing
13. Omit small words when reading
14. Write up/down hill
15. Difficulty aligning columns of numbers
16. Difficulty with reading comprehension
17. Inconsistent performance in work or sports
18. Postural changes when doing deskwork
19. Trouble keeping attention on reading
20. Difficult to stay on task
21. Difficulty trying new things
22. Avoiding physical activity that requires coordination
23. Poor eye/hand or fine motor coordination (i.e. handwriting)
24. Do not judge distances accurately.
25. Clumsy, knocks things over.
26. Poor time management
27. Do not count or make change well
28. Lose belongings/things
29. Car/motion sickness
30. Forgetful/poor memory

   Please provide the following contact information so we can send you the results:

First Name
Last Name
Phone ex. 405-444-5555
E-mail
Who does this describe?