Symptom Checklist

Please complete this questionnaire. After each symptom listed, circle the number that best describes how often you experience that particular problem

0=Never, 1= Seldom, 3= Frequently, 4= Always

Blurred Vision at Near: 0 1 2 3 4

Double Vision: 0 1 2 3 4

Headaches Associated with Near Work: 0 1 2 3 4

Burning, Stinging, Watery Eyes: 0 1 2 3 4

Words Run Together When Reading: 0 1 2 3 4

Falling Asleep When Reading: 0 1 2 3 4

Skipping or Repeating Lines When Reading: 0 1 2 3 4

Difficulty Copying from the Chalkboard: 0 1 2 3 4

Head Tilt or Closing of One Eye When Reading: 0 1 2 3 4

Reversals of Letters Like b,d,p,q: 0 1 2 3 4

Omitting Small Words When Reading: 0 1 2 3 4

Reading Comprehension Declining Over Time: 0 1 2 3 4

Inconsistent/Poor Sports Performance: 0 1 2 3 4

Holding Reading Material/Video Games Too Close: 0 1 2 3 4

Short Attention Span: 0 1 2 3 4

Difficulty Completing Assignments in Reasonable Time: 0 1 2 3 4

Avoiding Sports and Games: 0 1 2 3 4

Car Sickness/Motion Sickness: 0 1 2 3 4

Forgetful, Poor Memory: 0 1 2 3 4

If your child scored a 3 or higher on 3 symptoms or more, please contact our office to schedule a Binocular Exam.