HISTORY SUPPLEMENT FOR STUDENTS (6 – 17 yo) Patient Name* School performance up to potential. YES NO Difficulties with 3-D movies / books (ie headaches, eyestrain, blurriness, inability to appreciate 3-D). YES NO Reversals when reading (was – saw, on – no) or writing (b for d, p for q). YES NO Transposition of letters or numbers (21 for 12). YES NO Uses finger as marker when reading YES NO Skips and rereads words and/or letters- YES NO Blurred vision with reading, writing, or computer. YES NO Complains of print “running together” or “jumping around.” YES NO Blurred distance vision after prolonged reading, writing, computer YES NO Poor handwriting. YES NO Clumsiness, or poor eye-hand coordination YES NO Double vision YES NO . Near Far Headaches associated with visual tasks YES NO Reports sensation of eyes “not working together.” YES NO One eye turns in or out, up or down at any time YES NO Experiences unusual fatigue or eye pain with visual concentration. YES NO Excessive YES NO . Tearing Blinking Red eyes Rubbing eyes Tilts or turns head excessively YES NO Closes or covers one eye in bright light or during visual tasks. YES NO Moves head forward or backward while looking at an object near or far YES NO Makes errors while copying from board/computer to paper. YES NO Avoids reading / close work YES NO Holds book too closely. YES NO Apparent intellect matches academic performance YES NO Completed by Date MM slash DD slash YYYY Please print, fill out and bring the History Supplement for Students form with you to the practice.