Harmony Vision Care - Symptom Survey

• HOME
• TREATMENTS
• ADULTS
• KIDS
• ABOUT
• RESOURCES
• CONTACT

Symptom Survey

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 request an evaluation, please make note of your score as you will need this when making an appointment.

Please tick 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

Your 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

Many children and adults do not realise that their struggles in the classroom or workplace are in no way linked to intelligence or how hard they are trying, instead they are not able to visually process the information put before them. These types of vision problems are called Functional Vision Disorders or Visual Dysfunction.

Contact us for more information or request a consultation >>