CHILDREN’S VISUAL SYMPTOMS CHECKLIST
After each symptom listed, circle the number that best describes how often your child experiences these behaviors.
The number 0 means your child NEVER has these behaviors, a 4 means your child ALWAYS has these behaviors.
Symptoms Never Always
1. Headache above one or both eyebrows _____________ 0 1 2 3 4
2. Words run together when reading or on the computer _____________ 0 1 2 3 4
3. Has a eye that turns in or out ________ 0 1 2 3 4
4. Avoids reading, especially small print _________ 0 1 2 3 4
5. Double vision ___ ___ 0 1 2 3 4
6. Lose place when reading ____0 1 2 3 4
7. Difficulty concentrating when reading or on the computer 0 1 2 3 4
8. Blurry vision in distance and/ or near during or at the end of day 0 1 2 3 4
9. Get too close to the book, computer screen, or television 0 1 2 3 4
10. Fill in the wrong “bubbles” on a computer graded test 0 1 2 3 4
11. Falls asleep when reading 0 1 2 3 4
12. Closes one eye or tilt head when reading or on the computer 0 1 2 3 4
13. Eyes burn, or feel tired 0 1 2 3 4
14. Slow or inaccurate when copying from board or overhead 0 1 2 3 4
15. Omits small words when reading 0 1 2 3 4
16. Write “uphill” or “downhill” 0 1 2 3 4
17. Misaligns or misplaces numbers in columns 0 1 2 3 4
18. Inconsistent or poor at sports 0 1 2 3 4
19. Carsickness, or motion sickness 0 1 2 3 4
20. Uses finger to keep place when reading 0 1 2 3 4
21. Writes letters or numbers backwards 0 1 2 3 4
22. Has persistent difficulty learning to spell 0 1 2 3 4