Austin Vision Therapy Symptom Checklist Functional Vision Symptom Checklist First Name Last Name Email Phone Any of the following symptoms may indicate a functional vision problem. Functional vision problems can negatively impact reading, learning, work productivity, and quality of life. Please read and mark the symptoms that occur. This is a critical step in determining the type and amount of functional vision problems that may exist. Do you or your child (check all that apply): 1. Skip lines while reading or copying2. Lose your place while reading or copying3. Skip words while reading or copying4. Substitute words while reading or copying5. Reread words or lines6. Reverse letters, numbers or words7. Use a finger or marker to keep place while reading or writing8. Read very slowly9. Experience poor reading comprehension10. Experience difficulty remembering what you have read11. Hold your head very close (within 7-8 inches) to your reading and/or writing material12. Squint, close or cover one eye while reading13. Tilt your head in an unusual posture when reading or writing14. Experience headaches after intense visual activities (reading or computer work)15. Notice that your eyes hurt or feel tired after close work16. Feel unusually tired after completing a visual task17. Experience double vision18. Notice that vision blurs at a distance when looking up from near work19. Experience crooked or poorly spaced writing20. Notice that print seems to move or go in and out of focus when reading21. Experience poor spelling skills22. Find that letters or lines “run together” when reading23. Find that words appear to jump on the page when reading24. Misalign letters and numbers25. Make errors when copying26. Experience difficulty tracking moving objects such as balls, etc.27. Experience unusual clumsiness or poor coordination28. Experience difficulty with eye-hand coordination sports such as baseball, etc.29. Experience an eye that turns in or out30. See more clearly with one eye than the other with best glasses prescription31. Feel sleepy while reading32. Dislike tasks requiring sustained concentration33. Confuse right and left directions34. Become restless when working at a desk35. Tend to lose awareness of surroundings when concentrating36. Find you must “feel” things to see them37. Suffer from carsickness or motion sickness38. Experience unusual blinking39. Experience unusual eye rubbing40. Experience dry eyes41. Experience watery eyes42. Experience red eyes43. Experience sensitivity to light 15-20 points= Possible functional vision problem 21-30 points= Probable functional vision problem 30+ points = Definite functional vision problem 15+ Points = Functional Vision Evaluation Recommended YOUR SCORE Need assistance with this form?