Adults and School Age Pre-Screening Questionnaire Name* First Last Contact Phone*Email* Preferred method of contact*PhoneEmailPreferred location*Pecan ParkWestlakeSan AntonioCommentsDate Date Format: MM slash DD slash YYYY Persons' NameProfessional's NamePlease rate the following signs and symptoms according to your current observations and/or your patient's current reports about how his/her eyes feel. Indicate the frequency of these signs and symptoms using the following number scale: Score 0 for Never, 1 for Infrequently, 2 for Sometimes, 3 for Fairly Often, 4 for Always Legend: N= Never , I= Infrequently , S= Sometimes , FO= Fairly Often , A= AlwaysEyes feel tired while reading or doing close work*NISFOAEyes feel uncomfortable while reading or doing close work*NISFOAHeadaches when reading or doing close work*NISFOAFeels sleepy when reading or doing close work*NISFOALoss of concentration when reading or doing close work*NISFOATrouble remembering what he/she has read*NISFOAReports double vision when reading or doing close work*NISFOAWords move, jump, swim, or appear to float on the page*NISFOASlow reader*NISFOAEyes hurt when reading or doing close work*NISFOAEyes feel sore when reading or doing close work*NISFOA"Pulling feeling" around eyes when reading or doing close work*NISFOAWords blur or go in and out of focus when reading or doing close work*NISFOALoss of place while reading or doing close work*NISFOARe-reads the same line of words or omits words when reading*NISFOAReversal errors when reading (was for saw, on for no) or writing (b for d)*NISFOATransposes letters or numbers (21 for 12)*NISFOADifficulties copying from the board/book/paper/computer screen*NISFOAPoor printing or handwriting*NISFOAAvoidance of reading*NISFOADifficulties completing school assignments in a timely manner*NISFOAMisaligns digits or columns when doing math assignments*NISFOASeems to be clumsy or knock things over*NISFOAOverlooks small details (read beak for break) or misreads math symbols (- for +)*NISFOAShort attention span/easily distracted when reading or doing school work*NISFOASub TotalsTotal Score**Total scores greater than or equal to 16 warrant a consultation with a Developmental Optometrist specializing in the diagnosis and treatment of Vision-Related Learning Problems.EmailThis field is for validation purposes and should be left unchanged.