Preschool Questionnaire "*" indicates required fields Date* MM slash DD slash YYYY Name* First Last Phone*Email* Child's Name*Professional'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= AlwaysComplaints of tired eyes during or after close work* N I S FO A Complaints of eyes hurting during or after close work* N I S FO A Complaints of headaches during or after doing close work* N I S FO A Complaints of being tired during or after doing close work* N I S FO A Distracted/inattentive when doing close work* N I S FO A Reports seeing double when doing close work* N I S FO A Frequent tilting of the head* N I S FO A Frequent rubbing of the eyes* N I S FO A Squinting when looking at objects* N I S FO A Consistently sitting close to the TV or holding a book to close* N I S FO A Holding objects close to their nose to view* N I S FO A Closing one eye to read, watch tv, or see better* N I S FO A Turning of an eye in or out* N I S FO A Poor eye hand coordination* N I S FO A Avoidance of table top work such as coloring, puzzles, other detailed activities* N I S FO A Difficulty completing tasks/assignments in a timely manner* N I S FO A Seems to be clumsy or knock things over* N I S FO A Overly cautious on steps or curbs* N I S FO A Short attention span/easily distracted for the child's age* N I S FO A Not reaching their academic potential* N I S FO A Sub TotalsTotal Score**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. NameThis field is for validation purposes and should be left unchanged.