Adult Questionnaire

Adult Questionnaire for Vision Problems

To take the vision quiz, check the column which best represents the occurrence of each symptom.

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Blurry when looking at near?


Complain of frequent headaches?


Do you see worse at the end of the day?


Difficulty copying from the chalkboard?


Avoid near work/reading?


Hold your head too close to the page?


Do you have double vision?


Words run together while reading?


Eyes burn, itch, or seem watery?​​​​​​​


Do you fall asleep while reading?
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Do you close one eye or tilt your head while reading?​​​​​​​


Dizzy or nauseous with near work?
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Do you write up or down hill?


Poor/inconsistent in sports?
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Do you avoid sports/games?


Poor hand-eye coordination/poor handwriting?
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Clumsy/knock things over?


Do you experience car/motion sickness?
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Skip or repeat lines when reading?


Misalign digits/columns of numbers?
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Reading comprehension is poor?


Trouble keeping attention while reading?
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Do you say, "I can't" before trying?


Don't use your time well?
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Don't make change well with money?


Do you lose belongings/things?
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Forgetful or poor memory?
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Do you have difficulty completing assignments on time?
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Does not judge distance accurately?​​​​​​​
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First Name:


​​​​​​​Your Score: