Comprehensive Eye Exam Symptom Survey

Blurred vision at near

Double vision

Headaches associated with near work

Words run together when reading

Burning, stinging, watery eyes

Falling asleep when reading

Vision worse at the end of the day

Skipping or repeating lines when reading

Dizziness or nausea associated with near work

Head tilt or closing one eye when reading

Difficulty copying from the chalkboard

Avoidance of reading and near work

Omitting small words when reading

Writing uphill or downhill

Misaligning digits in columns of numbers

Reading comprehension declining over time

Inconsistent/poor sports performance

Holding reading material too close

Short attention span

Difficulty completing assignments in reasonable time

Saying "I can't" before trying

Avoiding sports and games

Difficulty with hand tools-scissors, screwdriver, calculator, keys

Inability to estimate distances accurately

Tendency to knock things over on desk or table

Difficulty with time management

Difficulty with money concepts, making change

Misplaces or loses papers, objects, belongings

Car sickness/motion sickness

Forgetful, poor memory