Parent Questionnaire for Preschool

Parent Questionnaire for Preschool Vision Problems

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

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Physical Signs

Report that books or other things look blurry?

Complain of frequent headaches?

Blink excessively or rub their eyes?​​​​​​​

Hold books extremely close?​​​​​​​

Cover one eye by leaning on hand?

Experience car sickness/motion sickness?

Performance Problems

Use eyes and hands together well?

Draw and name pictures accurately.

Color within lines?

Tend towards clumsiness?

Reverse letters and numbers?

Have a tendency to knock things over on a desk or table?

Have difficulty with hand tools - scissors, calculator, keys, etc?

Secondary Symptoms

Have a short attention span?

Have poor self-esteem and confidence in school?

Misbehave or ‘goof off’ during structured learning time?

Have frustration and anxiety associated with learning?

Seem to perform up to their potential?

Inability to estimate distances accurately

Difficulty with time management

Difficulty with money concepts, making change

Misplaces or loses papers, objects, belongings

Forgetful, poor memory

FIrst Name:

Your Score: