Functional Vision Symptom Checklist

Any of the following symptoms may indicate a functional vision problem. Please mark the symptoms that occur and use the scoring criteria which will automatically calculate at the bottom of the page to determine if a functional vision evaluation is recommended.

If you would like to schedule an evaluation, please make note of your score as you will need this when scheduling. Or, you can email us for a free report by clicking on the box at the right. We will send you a more detailed report on your results from the test.

Check all that apply:

Skip lines while reading or copying

Lose your place while reading or copying

Skip words while reading or copying

Substitute words while reading or copying

Reread words or lines

Reverse letters, numbers or words

Use a finger or marker to keep place while reading/writing

Read very slowly

Have poor reading comprehension (unless read to)

Have difficulty remembering what has been read

Hold your head too close when reading/writing (within 7-8″)

Squint, close or cover one eye while reading

Have unusual posture/head tilt when reading/writing

Have headaches following intense reading/computer work

Have eyes that hurt or feel tired after close work

Feel unusually tired after completing a visual task

Have double vision

Notice vision blurs at distance when looking up from near work

Have crooked or poorly spaced writing

Notice that print seems to move or go in and out of focus

Have poor spelling skills

Notice that letters or lines “run together” or words “jump” when reading

Misalign letters or numbers

Make errors when copying

Have difficulty tracking moving objects

Notice unusual clumsiness, poor concentration

Have difficulty with sports involving good hand-eye coordination

Have an eye that turns in or out

See more clearly with one eye than the other

Feel sleepy while reading

Dislike tasks requiring sustained concentration

Avoid near tasks such as reading

Confuse right and left directions

Become restless when working at a desk

Tend to lose awareness of surroundings when concentrating

Find you must “feel” things to see them

Experience carsickness

Experience unusual blinking

Experience unusual eye rubbing

Experience dry eyes

Experience watery eyes

Experience red eyes

Have eyes that are bothered by light

Score:
0

Criteria:

15-20 points total = Possible functional vision problems
21-30 points total = Probable functional vision problems
Over 30 points total = Definite functional vision problems
15+ total points = Functional vision evaluation recommended

Call or email Minnesota Vision Therapy Center today to schedule a functional vision evaluation.

mvtc@minnesotavisiontherapy.com

952-844-0844

877-756-0844