Parent Questionnaire

Parent Questionnaire for 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 the blackboard or other things look blurry?

Have headaches after doing schoolwork?

Blink excessively or rub their eyes?

Hold books extremely close?​​​​​​​

Cover one eye by leaning on hand?

Fall asleep when reading?

Report that words run together when reading?

Performance Problems

Have trouble copying work from the chalkboard to paper?

Avoid reading?

Lose place when reading?

Skip or reread words and lines?

Have difficulty completing schoolwork in reasonable time?

Tend towards clumsiness

Reverse letters and numbers?

Secondary Symptoms

Have a short attention span?

Have poor self-esteem and confidence in school?

Misbehave or ‘goof off’ in school?

Have frustration and anxiety associated with school?

Seem to perform up to their potential?

Difficulty with hand tools-scissors, calculator, keys, etc.

Inability to estimate distances accurately

Tendency to knock things over on desk or table

Difficulty with time management

Difficulty with money concepts, making change

Misplaces or loses papers, objects, belongings

Car sickness/motion sickness​​​​​​​

Forgetful, poor memory

First Name:

​​​​​​​Your Score: