| Condition |
T |
B |
F |
VP |
| 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 |
|
| Difficulty tracking moving objects |
X |
X |
|
|
| Clumsiness or poor coordination |
X |
X |
X |
X |
| Unable to make a picture in your mind while reading |
|
|
|
X |
| Difficulty following instructions (written or verbal) |
|
|
|
X |
| Unable to remember a series of tasks |
|
|
|
X |
| Below grade level on standardized tests |
X |
X |
X |
X |
| Feel sleepy while reading |
X |
X |
X |
|
| Restless when working at a desk |
X |
X |
X |
X |
| Losing awareness of surroundings when concentrating |
X |
X |
X |
X |
| Car sickness or motion sickness |
X |
X |
X |
|
| Excessive eye rubbing |
X |
X |
X |
|
| Dry eyes |
X |
X |
X |
|
| Sensitivity to light |
X |
X |
X |
|
| Totals |
29 |
32 |
29 |
19 |
| Maximum Possible |
69 |
84 |
54 |
55 |
