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