Dizziness/Situational Survey

I have blurred vision when looking at near objects.

I have double vision (seeing two objects rather than one).

I have headaches with near work.

Words run together when I read.

My eyes burn, itch, water.

I fall asleep when I read.

I see worse at the end of the day.

I skip or repeat lines when reading.

I feel dizzy or sick to my stomach with near work.

I tilt my head or cover an eye when reading.

I have difficulty copying from the chalkboard.

I avoid reading and near work.

I leave out small words when reading.

I write uphill or downhill (my handwriting tends to slant up or down).

Columns of numbers appear misaligned.

I don't understand what I read.

I am poor in sports.

I hold my reading very close.

I have difficulty completing assignments on time.

I often say "I can't" before trying.

I avoid sports and games.

I have poor hand/eye coordination.

I do not judge distance accurately.

I am clumsy.

I do not use my time well.

I do not do well figuring out change (money).

I lose papers and belongings.

I have trouble with car/motion sickness.

I am forgetful with a poor memory.