| Condition |
T |
B |
F |
VP |
| Skip lines while reading or copying |
X |
X |
|
|
| Skip words while reading or copying |
X |
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 |
|
| Letters or lines “run together” or words appear to “jump” when reading |
X |
X |
|
|
| Difficulty tracking moving objects |
X |
X |
|
|
| Uses fingers to count for math |
|
|
|
X |
| Does not know math facts automatically |
|
|
|
X |
| Feel sleepy while reading |
X |
X |
X |
|
| Confuse right and left directions |
|
|
|
X |
| Losing awareness of surroundings when concentrating |
X |
X |
X |
X |
| Car sickness or motion sickness |
X |
X |
X |
|
| Sensitivity to light |
X |
X |
X |
|
| Totals |
28 |
31 |
19 |
10 |
| Maximum Possible |
69 |
84 |
54 |
55 |
