"*" indicates required fields

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
Complaints of tired eyes during or after close work*
Complaints of eyes hurting during or after close work*
Complaints of headaches during or after doing close work*
Complaints of being tired during or after doing close work*
Distracted/inattentive when doing close work*
Reports seeing double when doing close work*
Frequent tilting of the head*
Frequent rubbing of the eyes*
Squinting when looking at objects*
Consistently sitting close to the TV or holding a book to close*
Holding objects close to their nose to view*
Closing one eye to read, watch tv, or see better*
Turning of an eye in or out*
Poor eye hand coordination*
Avoidance of table top work such as coloring, puzzles, other detailed activities*
Difficulty completing tasks/assignments in a timely manner*
Seems to be clumsy or knock things over*
Overly cautious on steps or curbs*
Short attention span/easily distracted for the child's age*
Not reaching their academic potential*
**Total scores greater than or equal to 13 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.