Focus Academy - Quality of Life Checklist
Kelston Vourakes
Check the answer which best represents the occurrence of each symptom.
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
Name: *
Your answer
Patient Name: (If different than above)
Your answer
Phone Number: *
Your answer
Email Address: *
Your answer
Explain a little about your interest in vision therapy.
Your answer
Get link
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service