Blur when looking at near                                0 1 2 3 4 

Double vision, doubled or overlapping words on page      0 1 2 3 4 

Headaches while or after doing near vision work          0 1 2 3 4 

Words appear to run together when reading                0 1 2 3 4 

Burning, itching or watery eyes                          0 1 2 3 4 

Falls asleep when reading                                0 1 2 3 4 

Seeing and visual work is worse at the end of the day    0 1 2 3 4 

Skips or repeats lines while reading                     0 1 2 3 4 

Dizziness or nausea when doing near work                 0 1 2 3 4 

Head tilts or one eye is closed or covered while reading 0 1 2 3 4 

Difficulty copying from the chalkboard                   0 1 2 3 4 

Avoids doing near vision work such as reading            0 1 2 3 4 

Omits (drops out) small words while reading              0 1 2 3 4 

Writes up or down hill                                   0 1 2 3 4 

Misaligns digits or columns of numbers                   0 1 2 3 4 

Reading comprehension low, or declines as day wears on   0 1 2 3 4 

Poor, inconsistent performance in sports                 0 1 2 3 4 

Holds books too close, leans too close to computer screen 0 1 2 3 4 

Trouble keeping attention centered on reading            0 1 2 3 4 

Difficulty completing assignments on time                0 1 2 3 4 

First response is “I can’t” before trying                0 1 2 3 4 

Avoids sports and games                                  0 1 2 3 4 

Poor hand/eye coordination, such as poor handwriting     0 1 2 3 4 

Does not judge distances accurately                      0 1 2 3 4 

Clumsy, accident prone, knocks things over               0 1 2 3 4 

Does not use or plan his/her time well                   0 1 2 3 4 

Does not count or make change well                       0 1 2 3 4 

Loses belongings and things                              0 1 2 3 4 

Car or motion sickness                                   0 1 2 3 4 

Forgetful, poor memory                                   0 1 2 3 4