SYMPTOM TEST Substitute words while reading or copying Reread words or lines Reverse letters, numbers or words Use a finger or marker to keep place while reading/writing Read very slowly Have poor reading comprehension (unless read to) Have difficulty remembering what has been read Hold your head too close when reading/writing (within 7-8") Squint, close or cover one eye while reading Have unusual posture/head tilt when reading/writing Have headaches following intense reading/computer work Have eyes that hurt or feel tired after close work Feel unusually tired after completing a near visual task Have double vision or see 2 images Notice vision blurs at distance when looking up from near work Have crooked or poorly spaced writing Notice that print seems to move or go in and out of focus Have poor spelling skills Notice that letters or lines "run together" or words "jump" when reading Misalign letters or numbers Make errors when copying Have difficulty tracking moving objects Notice unusual clumsiness, poor concentration Have difficulty with sports involving good hand-eye coordination Have an eye that turns in or out See more clearly with one eye than the other Feel sleepy while reading Dislike tasks requiring sustained concentration Avoid near tasks such as reading Become restless when working at a desk Tend to lose awareness of surroundings when concentrating Find you must "feel" things to see them Experience carsickness Experience unusual blinking Experience unusual eye rubbing Experience dry eyes Experience watery eyes Experience red eyes Have eyes that are bothered by light Criteria 15 - 20 points total Possible functional vision problems 21 - 30 points total Probable functional vision problems Over 30 points total Definite functional vision problems YOUR SCORE 00 You must have JavaScript enabled to use this form. Full Name Date of Birth of Patient Email Address Phone Number Message
