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
 
 
 
 
 

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