Adults and School Age Pre-Screening Questionnaire

Name*

First Last

Contact Phone*

Email*

Preferred method of contact*

Phone
Email

Preferred location*

Pecan Park
Westlake
San Antonio

Comments

Date

Persons' Name

Professional's Name

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*

Sub Totals

Total 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.

Phone

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