VER COACHING

Athlete*

First NameLast Name

Organization/Program

Sport

Position

Dominant Hand (Right or Left)

Dominant Eye (Right or Left)

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Athlete's Age

Subject Instructions: Please answer the following questions about how your eyes feel when reading or doing close work.

Rows	Never	Not very often	Sometimes	Fairly Often	Always
Do your eyes feel tired when reading or doing close work?
Do your eyes feel uncomfortable when reading or doing close work?
Do you have headaches when reading or doing close work?
Do you feel sleepy when reading or doing close work?
Do you lose concentration when reading or doing close work?
Do you have trouble remembering what you have read?
Do you have double vision when reading or doing close work?
Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
Do you feel like you read slowly?
Do your eyes ever hurt when reading or doing close work?
Do your eyes ever feel sore when reading or doing close work?
Do you feel a “puffing” feeling around your eyes when reading or doing close work?
Do you notice the words blurring or coming in and out of focus when reading or doing close work?
Do you lose your place when reading or doing close work?
Do you have to re-read the same line of words when reading?

Total