Focus Academy - Quality of Life Checklist
Kelston Vourakes
Check the answer which best represents the occurrence of each symptom.
0 - NEVER
1 - SELDOM
2 - OCCASIONALLY
3 - FREQUENTLY
4 - ALWAYS
Double vision
Headaches with near work
Words run together
Burning, itchy, watery eyes
Falls asleep reading
Sees worse at the end of the day
Skips/repeats lines when reading
Dizzy/nauseated by near work
Head tilt/one eye closed to read
Difficulty copying from chalkboard
Avoids near work/reading
Omits small words when reading
Writes uphill/downhill
Misaligns digits/columns of numbers
Poor reading comprehension
Poor/inconsistent in sports
Holds reading too close
Trouble keeping attention on reading
Difficulty completing work on time
Says "I can't" before trying
Avoids sports/games
Poor hand/eye coordination
Poor handwriting
Does not judge distance accurately
Clumsy, knocks things over
Poor time management
Does not handle change well - trouble with transitions
Lose things/belongings
Car or motion sickness
Forgetfulness/poor memory
Scoring Information
<15 = Routine eye exam recommended
16-24 = Comprehensive exam with developmental OD recommended
>25 = Developmental vision problem likely, comprehensive exam with developmental OD strongly recommended

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