| Condition |
T |
B |
F |
VP |
| Lose your place while reading or copying |
X |
X |
|
|
| Reread words or lines |
X |
X |
|
|
| Use a finger or marker to keep place while reading/writing |
X |
X |
|
|
| Read very slowly |
X |
X |
X |
|
| Poor reading comprehension, difficulty remembering what you’ve read |
X |
X |
X |
X |
| Squint, close or cover one eye while reading |
|
X |
|
|
| Tilt head in an unusual posture when reading or writing |
|
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 |
|
| Difficulty tracking moving objects |
X |
X |
|
|
| Clumsiness or poor coordination |
X |
X |
X |
X |
| Difficulty with eye‐hand coordination sports such as baseball |
X |
X |
|
X |
| Does not know math facts automatically |
|
|
|
X |
| Unable to remember a series of tasks |
|
|
|
X |
| Below grade level on standardized tests |
X |
X |
X |
X |
| Dislike tasks requiring sustained concentration |
X |
X |
X |
X |
| You must feel things to “see” them |
|
|
|
X |
| Excessive blinking |
X |
X |
X |
|
| Dry eyes |
X |
X |
X |
|
| Sensitivity to light |
X |
X |
X |
|
| Totals |
38 |
44 |
23 |
19 |
| Maximum Possible |
69 |
84 |
54 |
55 |
