"*" indicates required fields

Name*
MM slash DD slash YYYY
Please 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= Always
Eyes feel tired while reading or doing close work*
Eyes feel uncomfortable while reading or doing close work*
Headaches when reading or doing close work*
Feels sleepy when reading or doing close work*
Loss of concentration when reading or doing close work*
Trouble remembering what he/she has read*
Reports double vision when reading or doing close work*
Words move, jump, swim, or appear to float on the page*
Slow reader*
Eyes hurt when reading or doing close work*
Eyes feel sore when reading or doing close work*
"Pulling feeling" around eyes when reading or doing close work*
Words blur or go in and out of focus when reading or doing close work*
Loss of place while reading or doing close work*
Re-reads the same line of words or omits words when reading*
Reversal errors when reading (was for saw, on for no) or writing (b for d)*
Transposes letters or numbers (21 for 12)*
Difficulties copying from the board/book/paper/computer screen*
Poor printing or handwriting*
Avoidance of reading*
Difficulties completing school assignments in a timely manner*
Misaligns digits or columns when doing math assignments*
Seems to be clumsy or knock things over*
Overlooks small details (read beak for break) or misreads math symbols (- for +)*
Short attention span/easily distracted when reading or doing school work*
**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.
This field is for validation purposes and should be left unchanged.