Adult Questionnaire

Adult Questionnaire for Vision Problems

To take the vision quiz, check the column which best represents the occurrence of each symptom.

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Blurry when looking at near?

Complain of frequent headaches?

Do you see worse at the end of the day?

Difficulty copying from the chalkboard?

Avoid near work/reading?

Hold your head too close to the page?

Do you have double vision?

Words run together while reading?

Eyes burn, itch, or seem watery?​​​​​​​

Do you fall asleep while reading?

Do you close one eye or tilt your head while reading?​​​​​​​

Dizzy or nauseous with near work?

Do you write up or down hill?

Poor/inconsistent in sports?

Do you avoid sports/games?

Poor hand-eye coordination/poor handwriting?

Clumsy/knock things over?

Do you experience car/motion sickness?

Skip or repeat lines when reading?

Misalign digits/columns of numbers?

Reading comprehension is poor?

Trouble keeping attention while reading?

Do you say, "I can't" before trying?

Don't use your time well?

Don't make change well with money?

Do you lose belongings/things?

Forgetful or poor memory?

Do you have difficulty completing assignments on time?

Does not judge distance accurately?​​​​​​​

First Name:

​​​​​​​Your Score: