Quality of Life Checklist
Please fill out the fields below and check the boxes indicating which symptoms you or your child displays and the frequency at which they occur.
Patient Name:
First Name
Last Name
Age of Patient:
Form Completed By:
First Name
Last Name
Date:
-
Month
-
Day
Year
Date
Contact Person Email:
example@example.com
Contact Person Phone Number:
Vision Symptoms:
Never
0
Seldom
1
Occasionally
2
Frequently
3
Always
4
Blurred close vision
Double vision
Headaches with near work
Words run together when reading
Burning, itchy, watery eyes
Falls asleep reading
Sees worse at the end of the day
Skips/repeats lines when reading
Dizzy/nauseated by near work
Head tilt/one eye closed to read
Difficulty copying from chalkboard
Avoids near work/reading
Omits small words when reading
Writes uphill/downhill
Misaligns digits or columns of numbers
Poor reading comprehension
Poor/inconsistent in sports
Holds reading too close
Trouble keeping attention on reading
Difficulty completing work on time
Says "I can't" before trying
Avoids sports/games
Poor hand/eye coordination
Poor handwriting
Does not judge distance accurately
Clumsy, knocks things over
Poor time use/management
Does not make change well
Loses things/belongings
Car or motion sickness
Forgetfulness/poor memory
Total:
< 15 = Routine eye exam recommended
16-24 = Comprehensive exam with developmental OD recommended
> 25 = Developmental vision problem likely, comprehensive exam with developmental OD strongly recommended
Please describe any additional symptoms not listed above:
Would you like a representative of A Chance To Grow to contact you to discuss specific services offered by A Chance To Grow?
Yes
No
Submit
Should be Empty: