Visual Symptom Survey

Visual Symptom Survey

This survey has been shown to help identify such conditions and will instantly tell you the likelihood that one is present.

Please indicate below how often the following symptoms are experienced by you or your child.

	Never	Seldom	Occasionally	Frequently	Always
Headaches with near work
Words run together while reading
Burning, itchy, or watery eyes
Skipping/repeating lines while reading
Tilting head or closing one eye when reading
Difficulty copying from a chalkboard
Avoiding near work or reading
Omitting small words when reading
Writing uphill or downhill
Misaligning digits/columns of numbers
Poor reading comprehension
Holding books or near work very close to eyes
Short attention span with near work
Difficulty completing assignments on time
Saying "I can't" before trying something
Clumsiness and knocking things over
Poor use of time
Losing belongings or misplacing things
Forgetting things

Symptom Survey Score
Your score indicates a high likelihood that you have a binocular vision problem that is affecting your performance in work, school, athletics, and other areas of your life.

It is recommended that you see a developmental optometrist for an evaluation. These services are offered right here at Apple Valley Vision with Dr. Brian Rowley or Dr. Blake.

Please click here to schedule your appointment today, or you may call our office at (801) 465-0355 , or click to chat live to speak with one of our excellent staff members who will help you schedule your appointment.
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