Children Vision Questionnaire

Monday: By Appointment Only
Tuesday: 11:00 AM - 7:00 PM
Wednesday: 11:00 AM - 7:00 PM
Thursday: 9:00 AM - 5:00 PM
Friday: 9:00 AM - 5:00 PM
Saturday: 9:00 AM - 2:00 PM
Sunday: Closed

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	0 = symptom not present	1 = symptom minimally present	2 = symptom moderately present	3 = symptom severely present
Double vision
Blurred vision at near
Head tilt or closing one eye when reading
Headaches associated with near work
Words run together when reading
Falling asleep when reading
Vision worse at the end of the day
Holding reading material too close
Uses finger when reading
Poor ability to remember what is read
Confuses similar words
Fails to recognize same word in next sentence/page
Skipping or repeating words/lines when reading
Mis-aligning digits in columns of numbers
Difficulty with holding scissors, keys
Poor hand writing
Avoiding sports and games
Inability to estimate distances accurately
Car sickness/motion sickness
Difficulty copying from white board
Reverses letters, numbers or words
Difficulty in spelling
Difficulty in math
Poor comprehension

MEDICAL HISTORY