| Condition |
T |
B |
F |
VP |
| Close (within 7‐8″) to reading and/or writing material |
|
X |
X |
|
| Squint, close or cover one eye while reading |
|
X |
|
|
| Headaches after intense visual activities such as reading or computer work |
X |
X |
X |
|
| Eyes hurt or feel tired after close work |
X |
X |
X |
|
| Unusually tired after completing a visual task |
X |
X |
X |
|
| Vision blurs at distance when looking up from near work |
|
X |
X |
|
| Crooked or poorly spaced writing |
|
|
|
X |
| Print moves or goes in and out of focus when reading |
|
X |
X |
|
| Difficulty tracking moving objects |
X |
X |
|
|
| Poor word recall & recognition |
|
|
|
X |
| Uses fingers to count for math |
|
|
|
X |
| Does not know math facts automatically |
|
|
|
X |
| Unable to remember a series of tasks |
|
|
|
X |
| Feel sleepy while reading |
X |
X |
X |
|
| Dislike tasks requiring sustained concentration |
X |
X |
X |
X |
| Avoid near tasks such as reading |
X |
X |
X |
|
| Confuse right and left directions |
|
|
|
X |
| Restless when working at a desk |
X |
X |
X |
X |
| Car sickness or motion sickness |
X |
X |
X |
|
| Excessive blinking |
X |
X |
X |
|
| Excessive eye rubbing |
X |
X |
X |
|
| Dry eyes |
X |
X |
X |
|
| Watery eyes |
X |
X |
X |
|
| Sensitivity to light |
X |
X |
X |
|
| Red eyes |
X |
X |
X |
|
| Totals |
28 |
40 |
34 |
21 |
| Maximum Possible |
69 |
84 |
54 |
55 |
