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Questionnaire for Visual Efficiency Problems

Mark the frequency noted of the following problems.  Any problems that are noted as "usually" or "always" are a concern and should be evaluated.

Focus Problems (Ocular Accommodation)

Not at
all

Just a
little

Usually

Always

   Squints to see school white board

   

 

 

 

   Blurred vision after deskwork

   

   

 

 

   Blinks a lot with deskwork

   

   

 

 

   Rubs eyes during or after deskwork  

   

   

 

 

   Very close working distance with work

   

   

 

 

   Headaches with deskwork 

   

   

 

 

   A pulling sensation around the eyes 

    

    

 

 

   Print seems to move when reading

 

 

 

 

   Avoidance of reading and other work

   

   

 

 

   Sensitivity to light

   

   

 

 

   Loss of reading comprehension w/time

   

   

 

 

   Difficulty copying from the whiteboard

   

   

 

 

Eye Movement Problems (Ocular Motor
     
(the following relate to reading) 

Not at
all

Just a
little 

Usually

Always

   Frequent loss of place  

   

   

 

 

   Moves head excessively 

   

   

 

 

   Skips words 

   

   

 

 

   Skips lines 

   

   

 

 

   Needs finger or marker to keep place 

   

   

 

 

   Slow reading speed 

   

   

 

 

   Rereads lines unknowingly 

   

   

 

 

   Poor comprehension 

   

   

 

 

   Difficulty copying from the whiteboard 

   

   

 

 

   Difficulty with columns of numbers  

   

   

 

 

Eye Teaming Problems (Binocularity) 

Not at
all 

Just a little 

Usually 

Always 

   Complains of seeing double 

   

   

 

 

   Parent notes (right/left) eye drift

   

   

 

 

   Frontal headaches with deskwork

   

   

 

 

   Eyestrain and fatigue with deskwork

   

   

 

 

   Letters or words float or move w/reading

   

   

 

 

   Squints or covers one eye with work

   

   

 

 

   Posture is slumped with deskwork

   

   

 

 

   Difficulty using binoculars

   

   

 

 

   Very close working distance w/work

   

   

 

 

   Car or motion sickness

   

   

 

 

   Difficulty concentrating with reading

   

   

 

 

   Loss of reading comprehension w/time

   

   

 

 

   A pulling sensation around the eyes

   

   

 

 

   Closes one eye in bright lights/beach

   

   

 

 

 


 


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