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Vision Therapy Questionnaire

  • MM slash DD slash YYYY
  • Please assign a value between 0 and 4 for each symptom 0= never or non-existent 1= seldom 2= occasionally 3=frequently 4= always
  • Never or non-existentSeldomOccasionallyFrequentlyAways
    Blurred vision at near
    Double vision
    Headaches associated with near work
    Burning, stinging, watery eyes
    Falling asleep when reading
    Vision worse at the end of the day
    Skipping or repeating lines when reading
    Dizziness or nausea associated with near work
    Head tilt or closing one eye when reading
    Difficulty copying from the chalkboard
    Avoidance of reading and near work
    Omitting small words when reading
    Writing uphill or downhill
    Misaligning digits in columns of numbers
    Reading comprehension declining over time
    lnconsistent/poor sports performance
    Holding reading material too close
    Short attention span
    Difficulty completing assignments in reasonable time
    Saying "I can't" before trying
    Avoiding sports and games
    Difficulty with hand tools - scissor, screwdriver, calculator, keys
    Inability to estimate distances accurately
    Tendency to knock things over on desk or table
    Difficulty with time management
    Difficulty with money concepts, making change
    Misplaces or loses papers, objects, belongings
    Car Sickness/motion sickness
    Forgetful, poor memory