Eyestrain Self Test

Please answer these questions pertaining to you or your child accordingly.

Check the most appropriate answer.
N= Never, S= Sometimes, O= Often, A= Always

1. Blur When Looking at Near?-----------------------------------------------------------------	N S O A
2. Double Vision? ------------------------------------------------------------------------------------	N S O A
3. Headaches with Near Work?-----------------------------------------------------------------	N S O A
4. Words Run Together When Reading?--------------------------------------------------	N S O A
5. Burning, Itching, Watery Eyes?-------------------------------------------------------------	N S O A
6. Falls Asleep When Reading?----------------------------------------------------------------	N S O A
7. Sees Worse at the End of the Day?-------------------------------------------------------	N S O A
8. Skips/Repeats Lines When Reading?---------------------------------------------------	N S O A
9. Dizzy/Nausea with Near Work?------------------------------------------------------------	N S O A
10. Head Tilt or Close One Eye When Reading?----------------------------------------	N S O A
11. Difficulty Copying From the Chalkboard?-------------------------------------------	N S O A
12. Avoids Near Work / Reading?-------------------------------------------------------------	N S O A
13. Omits Small Words When Reading?----------------------------------------------------	N S O A
14. Writes Up or Down Hill?---------------------------------------------------------------------	N S O A
15. Misaligns Digits / Columns of Numbers?---------------------------------------------	N S O A
16. Reading Comprehension Poor?---------------------------------------------------------	N S O A
17. Poor / Inconsistent in Sports?------------------------------------------------------------	N S O A
18. Holds Reading Too Close?----------------------------------------------------------------	N S O A
19. Trouble Keeping Attention on Reading?--------------------------------------------	N S O A
20. Difficulty Completing Assignments on Time? -------------------------------------	N S O A
21. Says "I Can't" Before Even Trying?----------------------------------------------------	N S O A
22. Avoids Participation in Sports / Games?---------------------------------------------	N S O A
23. Poor Hand / Eye ( Poor Handwriting )?------------------------------------------------	N S O A
24. Does Not Judge Distance Accordingly?----------------------------------------------	N S O A
25. Clumsy Knocks Over Things?------------------------------------------------------------	N S O A
26. Does Not Use Time Well?--------------------------------------------------------------------	N S O A
27. Does Not Make Change Well?------------------------------------------------------------	N S O A
28. Loses Belongings / Things?--------------------------------------------------------------	N S O A
29. Car Motion or Sickness?-------------------------------------------------------------------	N S O A
30. Forgetful / Poor Memory?------------------------------------------------------------------	N S O A

Now Score the Test:

N = 0 ..........S = 1 ...........O = 2 ...........A = 3

Add the numbers of A, O, S�s and multiply that by the number corresponding number above.

Then Add the Three final numbers together to achieve your final score.

If your score is 15-25 then your Quality of Life is somewhat affected by your visual system.
If your Score is 25 or greater then your Quality Of Life is significantly affected by your visual
system and an evaluation is strongly recommended.

Example: 5 S x 1 = 5 10 O x 2 = 20 15 A x 3 = 45 Total = 70
Binocular Vision Exam is Strongly Indicated