610-489-1828

115 W. Main Street, Suite B
Collegeville, PA 19426

Vision Quiz

COVD Quality of Life Checklist

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

Category

Symptom

Never

Seldom

Occas.

Freq.

Always

ABlur when looking at near
AHeadaches with near work
ASees worse at end of the day
ADifficulty copying from the Chalkboard
AAvoids near work/reading
AHolds head too close to the page
BHas double vision
BWords run together while reading
BEyes burn, itch, or seem watery
BFalls asleep while reading
BCloses one eye or tilts head while reading
ORDizzy or nauseous with near work
ORWrites up or down hill
ORPoor/inconsistent in sports
ORAvoids sports/games
ORPoor hand-eye coordination/poor handwriting
ORClumsy/knocks things over
ORCar/motion sickness
OMSkips or repeats lines when reading
OMMisaligns digits/columns of numbers
PReading comprehension is poor
PTrouble keeping attention on reading
PSays “I can’t” before trying
PDoes not use his/her time well
PDoes not make change well with money
PLoses belongings/things
PForgetful/poor memory
ALLDifficulty completing assignments on time
ALLDoes not judge distance accurately

Your Final Score:

Score >20 — There is a high risk of having a vision problem that makes it difficult to read, to learn, to comprehend and even to pay attention. Further evaluation with a Comprehensive Vision Examination is recommended.

Call 610-489-1828 or send us a secure email to schedule your appointment today!