Child's Name Age _________
First Name
Last Name
Do your child's eyes feel tired when they read or do close work?
*
Yes
No
Do their eyes feel uncomfortable when doing close work?
*
Yes
No
Do they get headaches when they read or do close work?
*
Yes
No
Do the eyes get sleepy...especially after reading or doing close work?
*
Yes
No
Does yor child have trouble remembering what they read?
*
Yes
No
Do they ever see doubles of letters, words, or numbers?
*
Yes
No
Do your child's eyes ever 'jump' when they're reading or go backwards... having to reread in close work?
Yes
No
Does your child ever skip lines, lose their place, or miscall words when reading or doing close work?
Yes
No
Does your child read slow and choppy...hesitating on words he or she knows already?
*
Yes
No
Does your child ever state that words blur or come out of focus when they do close work? (Assuming they don't need glasses or are already wearing reading glasses)
*
Yes
No
Submit
Should be Empty: