Consider each question, and write the answer that applies to your child. 

The test scores as follows:

Never-0; Seldom-1; Occasional-2; Frequent-3; Always-4

1.  Blur when looking near                                                                

2.  Double vision, doubled or overlapping words on page                  

3.  Headaches while or after doing near vision work                          

4.  Words appear to run together while reading                                 

5.  Burning, itching or watery eyes                                                     

6.  Falls asleep while reading                                                            

7.  Seeing and visual work is worse at the end of the day                  

8.  Skips or repeats lines while reading

9.  Dizziness or nausea when doing near work.

10. Head tilts or one eye is closed or covered while reading.

11. Difficulty copying from the chalkboard

12. Avoids doing near vision work such as reading.

13. Omits (drops out) small words while reading.

14. Writes up or down hill.

15. Misaligns digits or columns of numbers

16. Reading comprehension low, or declines as day wears on

17. Holds books too close, leans too close to computer screen

18. Trouble keeping attention centered on reading.

19. Poor, inconsistent performance in sports

20. Difficulty completing assignments on time

21. First response is "I can't" before trying

22. Avoids sports and games

23. Poor hand/eye coordination, such as poor handwriting

24. Does not judge distances accurately

25. Clumsy, accident prone, knocks things over

26. Does not use or plan his/her time well

27.  Does not count or make change well

28. Loses belongings and things

29. Car or motion sickness

30. Forgetful, poor memory

If your child scores between 20-24, using the scoring indicated above, they are suspect for a visual therapy evaluation, and if they are 25 or above they probably need to be referred for an evaluation.