Wondering if your child has an underlying eye condition? Fill out the survey below and contact our office to schedule your initial testing with a Vision Therapist: (620) 371-6330
You can also print this off and bring it with you to your consultation.
| How often do the following symptoms occur? | Never 0 | Not Often 1 | Sometimes 2 | A lot 3 | Always 4 |
| 1. Child reads below grade level |
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| 2. Stumbles over words when reading aloud |
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| 3. Loses places when reading |
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| 4. Leaves out small words when reading |
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| 5. Poor comprehension |
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| 6. Child doesn’t like reading |
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| 7. Turns head to side when reading |
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| 8. Covers eye or lays head down when reading |
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| 9. Holds book very close |
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| 10. Complains of headaches |
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| 11. Difficulty copying from the board |
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| 12. Hard to write in a straight line |
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| 13. Poor handwriting |
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| 14. Difficulty remaining on task |
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| 15. Struggles to finish assignments on time |
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| 16. Gives up easily |
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| 17. Daydreams or disruptive during class |
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| 18. Appears awkward or clumsy |
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| 19. Performs below potential |
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Multiply each column by the following numbers:
Never x0
Seldom x1
Sometimes x2
Often x3
Always x4
- Score below 20: Unlikely that vision is playing a large role in poor school performance
- 20-25: Fair possibility that poor visual skills are interfering with school performance
- 25-30: Likely probability that poor visual skills are interfering with school performance
- 30-35: Strong probability that poor visual skills are interfering with school performance
- Above 35: Near certainty that poor visual skills are interfering with school performance
*Disclaimer: this survey alone doesn't guarantee your child has poor visual skills. Real time testing, RightEye testing, amongst other evaluations will be done before a diagnosis is made.