Parent Questionnaire for Preschool

Parent Questionnaire for Preschool Vision Problems

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

Please know that email communication via our website may not be done through a secure platform. Although it is unlikely, there is a possibility that information you include in your submission can be intercepted and read by parties other than the intended recipient. To protect your confidential information, please do not include personal identifying information such as your birth date or personal medical information in any emails or website submissions you send to us.
​​​​​​​

Physical Signs


Report that books or other things look blurry?


Complain of frequent headaches?


Blink excessively or rub their eyes?​​​​​​​


Hold books extremely close?​​​​​​​


Cover one eye by leaning on hand?


Experience car sickness/motion sickness?

Performance Problems


Use eyes and hands together well?


Draw and name pictures accurately.


Color within lines?


Tend towards clumsiness?


Reverse letters and numbers?


Have a tendency to knock things over on a desk or table?


Have difficulty with hand tools - scissors, calculator, keys, etc?

Secondary Symptoms


Have a short attention span?


Have poor self-esteem and confidence in school?


Misbehave or ‘goof off’ during structured learning time?


Have frustration and anxiety associated with learning?


Seem to perform up to their potential?


Inability to estimate distances accurately


Difficulty with time management


Difficulty with money concepts, making change


Misplaces or loses papers, objects, belongings


Forgetful, poor memory

FIrst Name:


Your Score: