Symptom Checklist Please Check All Symptoms That Apply Skip lines while reading or copying Skip lines while reading or copying Skip words while reading or copying Skip words while reading or copying Lose your place while reading or copying Lose your place while reading or copying Substitute words while reading or copying Substitute words while reading or copying Reread words or lines Reread words or lines Reverse letters, numbers or words Reverse letters, numbers or words Use a finger or marker to keep place while reading/writing Use a finger or marker to keep place while reading/writing Read very slowly Read very slowly Poor reading comprehension, difficulty remembering what you've read Poor reading comprehension, difficulty remembering what you've read Close (within 7‐8″) to reading and/or writing material Close (within 7‐8″) to reading and/or writing material Squint, close or cover one eye while reading Squint, close or cover one eye while reading Tilt head in an unusual posture when reading or writing Tilt head in an unusual posture when reading or writing Headaches after intense visual activities such as reading or computer work Headaches after intense visual activities such as reading or computer work Eyes hurt or feel tired after close work Eyes hurt or feel tired after close work Unusually tired after completing a visual task Unusually tired after completing a visual task Vision blurs at distance when looking up from near work Vision blurs at distance when looking up from near work Crooked or poorly spaced writing Crooked or poorly spaced writing Print moves or goes in and out of focus when reading Print moves or goes in and out of focus when reading Poor spelling skills Poor spelling skills Letters or lines “run together” or words appear to “jump” when reading Letters or lines “run together” or words appear to “jump” when reading Misalign letters or numbers Misalign letters or numbers Make errors when copying Make errors when copying Difficulty tracking moving objects Difficulty tracking moving objects Clumsiness or poor coordination Clumsiness or poor coordination Difficulty with eye‐hand coordination sports such as baseball Difficulty with eye‐hand coordination sports such as baseball Unable to make a picture in your mind while reading Unable to make a picture in your mind while reading Poor word recall & recognition Poor word recall & recognition Uses fingers to count for math Uses fingers to count for math Does not know math facts automatically Does not know math facts automatically Difficulty following instructions (written or verbal) Difficulty following instructions (written or verbal) Unable to remember a series of tasks Unable to remember a series of tasks Below grade level on standardized tests Below grade level on standardized tests Feel sleepy while reading Feel sleepy while reading Dislike tasks requiring sustained concentration Dislike tasks requiring sustained concentration Avoid near tasks such as reading Avoid near tasks such as reading Confuse right and left directions Confuse right and left directions Restless when working at a desk Restless when working at a desk Losing awareness of surroundings when concentrating Losing awareness of surroundings when concentrating You must feel things to “see” them You must feel things to “see” them Car sickness or motion sickness Car sickness or motion sickness Excessive blinking Excessive blinking Excessive eye rubbing Excessive eye rubbing Dry eyes Dry eyes Watery eyes Watery eyes Red eyes Red eyes Sensitivity to light Sensitivity to light Your Personalized Score A score of 25 or more indicates a vision problem that can be helped with Vision Therapy at Home 15-25 = Possible visual problem 26-35 = Probable visual problem 36-60+ = Definite visual problem Once you have completed the above checklist, we can generate a personalized report explaining your results.Sign up for the report below. Child's First Name or Initial * Parent's First Name * Email Address * You will get immediate access to the report on the next page and we will email a link to the report for future reference. If you are human, leave this field blank.