Vision Assessment

This Quality of Life survey is designed especially for school-aged children, but many adults have grown up with similar vision problems and still experience poor performance during visually intense tasks.

There are 19 questions in all. 

This survey is not a substitute for consulting a physician, and does not provide diagnoses.

  1. Questions 1-10
  2. Questions 11-19
Headaches with near work.

Words run together when reading

Burning, itchy, watery eyes

Skips/repeats lines while reading

Tilts head/closes eyes while reading

Difficulty copying from chalkboard

Avoids near work/reading

Omits small words when reading

Writes up/down hill

Misaligns digits/columns of numbers

Reading comprehension down

Holds reading too close

Had trouble keeping attention on reading

Has difficulty completing assignments on time

Always says "I can't" before trying

Clumsy, knocks things over

Does not use time well

Loses things/belongings

Is forgetful/has a poor memory

Email Address

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