Child's Name*Email* Phone*One eye turns in or out at any timeNeverRarelySometimesFrequentlyConstantlyReddened eyes or lidsNeverRarelySometimesFrequentlyConstantlyEyes tear excessivelyNeverRarelySometimesFrequentlyConstantlyFrequent sties or encrusted eyelidsNeverRarelySometimesFrequentlyConstantlyFrequent blinkingNeverRarelySometimesFrequentlyConstantlySquinting or rubbing of the eyesNeverRarelySometimesFrequentlyConstantlyHeadaches in forehead or templesNeverRarelySometimesFrequentlyConstantlyBurning or itchy eyes after reading or desk workNeverRarelySometimesFrequentlyConstantlyPrint blurs after reading a short timeNeverRarelySometimesFrequentlyConstantlyComplains of seeing doubleNeverRarelySometimesFrequentlyConstantlyWords move or run togetherNeverRarelySometimesFrequentlyConstantlyWords get fat or develop a haloNeverRarelySometimesFrequentlyConstantlyHead turns as one reads across pageNeverRarelySometimesFrequentlyConstantlyLoses place frequently when readingNeverRarelySometimesFrequentlyConstantlyNeeds finger or marker to keep placeNeverRarelySometimesFrequentlyConstantlyShort attention span when reading or copyingNeverRarelySometimesFrequentlyConstantlyFrequently omits small wordsNeverRarelySometimesFrequentlyConstantlyRe-reads or skips lines unknowinglyNeverRarelySometimesFrequentlyConstantlyOmits letters, numbers or phrasesNeverRarelySometimesFrequentlyConstantlySquints, closes or covers one eyeNeverRarelySometimesFrequentlyConstantlyTilts head extremely when working at deskNeverRarelySometimesFrequentlyConstantlyMisaligns number and digit columnsNeverRarelySometimesFrequentlyConstantlyBumps into objectsNeverRarelySometimesFrequentlyConstantlyBothered by lightNeverRarelySometimesFrequentlyConstantlyMust feel things to get ideaNeverRarelySometimesFrequentlyConstantlyEyes not used to direct hand movementNeverRarelySometimesFrequentlyConstantlyWrites crookedly or poorly spacedNeverRarelySometimesFrequentlyConstantlyRepeatedly confuses left-right directionsNeverRarelySometimesFrequentlyConstantlyCrawled as a babyNeverRarelySometimesFrequentlyConstantlyFails to recognize same word in next sentenceNeverRarelySometimesFrequentlyConstantlyReverses letters and or words in writing and copyingNeverRarelySometimesFrequentlyConstantlyDifficulties in recognizing minor differencesNeverRarelySometimesFrequentlyConstantlyFails to visualize what is read silently or aloudNeverRarelySometimesFrequentlyConstantlyWhispers to self for reinforcement while reading silentlyNeverRarelySometimesFrequentlyConstantlyUses "drawing with fingers" to discriminate similarities and differencesNeverRarelySometimesFrequentlyConstantlyQuickly loses interest in readingNeverRarelySometimesFrequentlyConstantlyBlinks excessively at desk task or readingNeverRarelySometimesFrequentlyConstantlyHolds book to closely; face too close at deskNeverRarelySometimesFrequentlyConstantlyMakes errors in copying from page to paperNeverRarelySometimesFrequentlyConstantlySquints to see at distanceNeverRarelySometimesFrequentlyConstantlyRubs eyes during or after short periods of visual activityNeverRarelySometimesFrequentlyConstantlyBlinks to clear distance after reading or near taskNeverRarelySometimesFrequentlyConstantlyDizziness or nauseaNeverRarelySometimesFrequentlyConstantlyTrouble with balanceNeverRarelySometimesFrequentlyConstantlyCar sicknessNeverRarelySometimesFrequentlyConstantlyTrouble rememberingNeverRarelySometimesFrequentlyConstantlyTrouble paying attentionNeverRarelySometimesFrequentlyConstantlyReacts slowlyNeverRarelySometimesFrequentlyConstantlyThinks slowlyNeverRarelySometimesFrequentlyConstantlyHas trouble remembering to do things on timeNeverRarelySometimesFrequentlyConstantlyHas trouble planning, starting, doing and finishing a taskNeverRarelySometimesFrequentlyConstantlyNameThis field is for validation purposes and should be left unchanged.
