HISTORY SUPPLEMENT FOR STUDENTS (6 – 17 yo) Patient Name*School performance up to potential.YESNODifficulties with 3-D movies / books (ie headaches, eyestrain, blurriness, inability to appreciate 3-D).YESNOReversals when reading (was – saw, on – no) or writing (b for d, p for q).YESNOTransposition of letters or numbers (21 for 12).YESNOUses finger as marker when readingYESNOSkips and rereads words and/or letters-YESNOBlurred vision with reading, writing, or computer.YESNOComplains of print “running together” or “jumping around.”YESNOBlurred distance vision after prolonged reading, writing, computerYESNOPoor handwriting.YESNOClumsiness, or poor eye-hand coordinationYESNODouble visionYESNO. Near Far Headaches associated with visual tasksYESNOReports sensation of eyes “not working together.”YESNOOne eye turns in or out, up or down at any timeYESNOExperiences unusual fatigue or eye pain with visual concentration.YESNOExcessiveYESNO. Tearing Blinking Red eyes Rubbing eyes Tilts or turns head excessivelyYESNOCloses or covers one eye in bright light or during visual tasks.YESNOMoves head forward or backward while looking at an object near or farYESNOMakes errors while copying from board/computer to paper.YESNOAvoids reading / close workYESNOHolds book too closely.YESNOApparent intellect matches academic performanceYESNOCompleted byDate Date Format: MM slash DD slash YYYY Please print, fill out and bring the History Supplement for Students form with you to the practice.