Parent or Guardian must fill out questionnaire if child is under 12 years old

1. Do your eyes feel tired when reading or doing close work? Never Not Often Sometimes Fairly Often Always
2. Do your eyes feel uncomfortable when reading? Never Not Often Sometimes Fairly Often Always
3. Do you have headaches when reading? Never Not Often Sometimes Fairly Often Always
4. Do you feel sleepy when reading? Never Not Often Sometimes Fairly Often Always
5. Do you lose concentration when reading? Never Not Often Sometimes Fairly Often Always
6. Do you have trouble remembering what you have read? Never Not Often Sometimes Fairly Often Always
7. Do you have double vision when reading? Never Not Often Sometimes Fairly Often Always
8. Do you see the words move or jump when you read? Never Not Often Sometimes Fairly Often Always
9. Do you feel like you read slowly? Never Not Often Sometimes Fairly Often Always
10. Do your eyes ever hurt when reading? Never Not Often Sometimes Fairly Often Always
11. Do your eyes ever feel sore (i.e. achy) when reading? Never Not Often Sometimes Fairly Often Always
12. Do you ever feel a “pulling feeling” around your eyes? Never Not Often Sometimes Fairly Often Always
13. Do you notice words coming in and out of focus? Never Not Often Sometimes Fairly Often Always
14. Do you lose your place / line when reading? Never Not Often Sometimes Fairly Often Always
15. Do you have to re-read the same line when reading? Never Not Often Sometimes Fairly Often Always

Send answers

(0-14 normal, 15-20 borderline, 21-30 moderate, 30-40 high, 40-60 very high)

Submit your results to the clinic and we'll contact you by email to arrange a consultation.