Signs of a Vision Problem
Please select the frequency. If the question does not apply select 'never'.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Blur when looking up close
*
Never
Sometimes
Often
Double vision
*
Never
Sometimes
Often
Headaches working up close
*
Never
Sometimes
Often
Falls asleep when reading
*
Never
Sometimes
Often
Poor reading comprehension
*
Never
Sometimes
Often
Skips/repeats words/lines when reading
*
Never
Sometimes
Often
Loses place reading or copying
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Never
Sometimes
Often
Uses finger as a pointer
*
Never
Sometimes
Often
Tilts head/closes one eye when reading
*
Never
Sometimes
Often
Avoids near work/reading
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Never
Sometimes
Often
Print appears to move when reading
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Never
Sometimes
Often
Labeled “lazy”, “slow learner”, “AD(H)D” or “behavior problem”
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Never
Sometimes
Often
Dizziness/nausea with near work
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Never
Sometimes
Often
Misaligns digits or columns of numbers
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Never
Sometimes
Often
Excessive blinking/rubbing eyes
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Never
Sometimes
Often
Poor/inconsistent in sports
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Never
Sometimes
Often
Poor handwriting
*
Never
Sometimes
Often
Difficulty copying from chalkboard
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Never
Sometimes
Often
Clumsy/knocks things over
*
Never
Sometimes
Often
Car/motion sickness
*
Never
Sometimes
Often
Sees worse at the end of the day
*
Never
Sometimes
Often
Homework takes forever
*
Never
Sometimes
Often
The number of symptoms selected in your quiz:
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