| Condition |
T |
B |
F |
VP |
| Lose your place while reading or copying |
X |
X |
|
|
| Substitute words while reading or copying |
X |
X |
X |
|
| Reverse letters, numbers or words |
|
|
|
X |
| Read very slowly |
X |
X |
X |
|
| Eyes hurt or feel tired after close work |
X |
X |
X |
|
| Crooked or poorly spaced writing |
|
|
|
X |
| Print moves or goes in and out of focus when reading |
|
X |
X |
|
| Letters or lines “run together” or words appear to “jump” when reading |
X |
X |
|
|
| Misalign letters or numbers |
|
|
|
X |
| Poor word recall & recognition |
|
|
|
X |
| Does not know math facts automatically |
|
|
|
X |
| Difficulty following instructions (written or verbal) |
|
|
|
X |
| Avoid near tasks such as reading |
X |
X |
X |
|
| Losing awareness of surroundings when concentrating |
X |
X |
X |
X |
| You must feel things to “see” them |
|
|
|
X |
| Car sickness or motion sickness |
X |
X |
X |
|
| Totals |
21 |
24 |
18 |
25 |
| Maximum Possible |
69 |
84 |
54 |
55 |
