| Condition |
T |
B |
F |
VP |
| Lose your place while reading or copying |
X |
X |
|
|
| Reverse letters, numbers or words |
|
|
|
X |
| Read very slowly |
X |
X |
X |
|
| Poor reading comprehension, difficulty remembering what you’ve read |
X |
X |
X |
X |
| Close (within 7‐8″) to reading and/or writing material |
|
X |
X |
|
| Eyes hurt or feel tired after close work |
X |
X |
X |
|
| Unusually tired after completing a visual task |
X |
X |
X |
|
| Crooked or poorly spaced writing |
|
|
|
X |
| Clumsiness or poor coordination |
X |
X |
X |
X |
| Uses fingers to count for math |
|
|
|
X |
| Does not know math facts automatically |
|
|
|
X |
| Difficulty following instructions (written or verbal) |
|
|
|
X |
| Unable to remember a series of tasks |
|
|
|
X |
| Dislike tasks requiring sustained concentration |
X |
X |
X |
X |
| Restless when working at a desk |
X |
X |
X |
X |
| Losing awareness of surroundings when concentrating |
X |
X |
X |
X |
| Dry eyes |
X |
X |
X |
|
| Totals |
25 |
28 |
25 |
30 |
| Maximum Possible |
69 |
84 |
54 |
55 |
