Forms : Symptom Checklist

This predictive checklist was developed by optometrists and educators for the College of Vision Development (www.covd.org).

Any of the following symptoms may indicate a functional vision problem. Please rank the symptoms as they occur, and the score will total at the bottom automatically. A score of 20 or above may indicate a potential vision problem and should be assessed by a developmental optometrist.

If you would like to schedule a free evaluation, please print your completed checklist and call 913-469-8686.

	0: Never	1: Seldom	2: Occasional	3: Frequent	4: Always
Vision is blurry when looking at near objects
Double vision; Overlapping words on page
Headaches while or after doing near vision work
Words appear to run together when reading
Burning, itching or watery eyes
Falls asleep when reading
Seeing and visual work is worse at the end of the day
Dizziness or nausea when doing near work
Head tilts or one eye is closed or covered while reading
Difficulty copying from the chalkboard
Avoidance of near work, such as reading
Omits (drops out) small words while reading
Writes up or down hill
Misaligns digits or columns of numbers
Reading comprehension low or declines as day wears on
Poor, inconsistent performance in sports
Holds books too close, leans too close to computer
Trouble keeping attention centered on reading
Difficulty completing assignments on time
First response is "I can't" before trying
Avoids sports and games
Poor hand/eye coordination, such as poor handwriting
Does not judge distances accurately
Clumsy, accident prone, knocks things over
Does not use or plan his/her time well
Does not count or make change well
Loses belongings and things
Car or motion sick
Forgetful, poor memory
TOTAL SCORE					0