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Home » Patient Forms » Adults and School Age Pre-Screening Questionnaire

Adults and School Age Pre-Screening Questionnaire

Name(Required)
Preferred method of contact
Preferred location
MM slash DD slash YYYY
Please rate the following signs and symptoms according to your current observations and/or your patient's current reports about how his/her eyes feel. Indicate the frequency of these signs and symptoms using the following number scale:
Score 0 for Never, 1 for Infrequently, 2 for Sometimes, 3 for Fairly Often, 4 for Always
Eyes feel tired while reading or doing close work(Required)
Eyes feel uncomfortable while reading or doing close work(Required)
Headaches when reading or doing close work(Required)
Feels sleepy when reading or doing close work(Required)
Loss of concentration when reading or doing close work(Required)
Trouble remembering what he/she has read(Required)
Reports double vision when reading or doing close work(Required)
Words move, jump, swim, or appear to float on the page(Required)
Slow reader(Required)
Eyes hurt when reading or doing close work(Required)
Eyes feel sore when reading or doing close work(Required)
"Pulling feeling" around eyes when reading or doing close work(Required)
Words blur or go in and out of focus when reading or doing close work(Required)
Loss of place while reading or doing close work(Required)
Re-reads the same line of words or omits words when reading(Required)
Reversal errors when reading (was for saw, on for no) or writing (b for d)(Required)
Transposes letters or numbers (21 for 12)(Required)
Difficulties copying from the board/book/paper/computer screen(Required)
Poor printing or handwriting(Required)
Avoidance of reading(Required)
Difficulties completing school assignments in a timely manner(Required)
Misaligns digits or columns when doing math assignments(Required)
Seems to be clumsy or knock things over(Required)
Overlooks small details (read beak for break) or misreads math symbols (- for +)(Required)
Short attention span/easily distracted when reading or doing school work(Required)
**Total scores greater than or equal to 16 warrant a consultation with a Developmental Optometrist specializing in the diagnosis and treatment of Vision-Related Learning Problems.