Vision Symptom Survey

Distance vision blurred and not clear - even with lenses

Near vision blurred and not clear - even with lenses

Eye discomfort/sore eyes/eyestrain

Headaches or dizziness after using eyes

Eye fatigue/very tired after using eyes all day

Feel “pulling” around the eyes

Double vision - especially when tired

Have to close or cover one eye to see clearly

Print moves in and out of focus when reading

Normal indoor lighting is uncomfortable - too much glare

Ourdoor light too bright - have to use sunglasses

Indoor fluorescent lighting is bothersome or annoying

Clumsiness/Misjudge where objects really are

Lack of confidence walking/missing steps/stumbling

Poor handwriting (spacing, size, legibility)

Side vision distorted/objects move or change position

What looks straight ahead - isn’t always straight ahead

Avoid crowds/can’t tolerate “visually-busy” places

Short attention span/easily distracted when reading

Difficulty/slowness with reading and writing

Poor reading comprehension/can’t remember what was read

Confusion of words/skip words during reading

Lose place/have to use finger not to lose place when reading

After reading, do the words start to blur or move around the page?

Reversal issues: b/d or p/q?

Educational assistance in Math or Reading at school?

Difficulty recognizing social cues?

Is there a strong dislike of tight clothing or tags?

Coordination level (good at sports, or easily ride a bike?)

Have a strong dislike of changes?

Anxiety?

Emotional instability or sensitivity?

Family history of eye issues or lazy eye?

History of injuries or surgeries?

History of high fever(s) or recurrent ear infections?

History of abuse (verbal, physical, mental, etc.)?

History of developmental delay (crawling, walking, talking, etc.)?

Any recent life change (move, death, employment status, etc.)?