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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