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
A Blur when looking at near
A Headaches with near work
A Sees worse at end of the day
A Difficulty copying from the Chalkboard
A Avoids near work/reading
A Holds head too close to the page
B Has double vision
B Words run together while reading
B Eyes burn, itch, or seem watery
B Falls asleep while reading
B Closes one eye or tilts head while reading
OR Dizzy or nauseous with near work
OR Writes up or down hill
OR Poor/inconsistent in sports
OR Avoids sports/games
OR Poor hand-eye coordination/poor handwriting
OR Clumsy/knocks things over
OR Car/motion sickness
OM Skips or repeats lines when reading
OM Misaligns digits/columns of numbers
P Reading comprehension is poor
P Trouble keeping attention on reading
P Says “I can’t” before trying
P Does not use his/her time well
P Does not make change well with money
P Loses belongings/things
P Forgetful/poor memory
ALL Difficulty completing assignments on time
ALL Does not judge distance accurately

Your Final Score:

Score below 15 – Schedule for a routine eye exam
Score 16-24 — Schedule for visual functional problems
Score >25 — Schedule for a developmental vision evaluation

Call our Woodruff office at 715-358-4060 or our Wausau office at 715-845-6600 to make your appointment today!