Dizziness/Situational Survey Patient Name First Last Please check the column that best represents the occurrence of each symptom.I have blurred vision when looking at near objects.NeverSeldomOccasionallyFrequentlyAlwaysI have double vision (seeing two objects rather than one).NeverSeldomOccasionallyFrequentlyAlwaysI have headaches with near work.NeverSeldomOccasionallyFrequentlyAlwaysWords run together when I read.NeverSeldomOccasionallyFrequentlyAlwaysMy eyes burn, itch, water.NeverSeldomOccasionallyFrequentlyAlwaysI fall asleep when I read.NeverSeldomOccasionallyFrequentlyAlwaysI see worse at the end of the day.NeverSeldomOccasionallyFrequentlyAlwaysI skip or repeat lines when reading.NeverSeldomOccasionallyFrequentlyAlwaysI feel dizzy or sick to my stomach with near work.NeverSeldomOccasionallyFrequentlyAlwaysI tilt my head or cover an eye when reading.NeverSeldomOccasionallyFrequentlyAlwaysI have difficulty copying from the chalkboard.NeverSeldomOccasionallyFrequentlyAlwaysI avoid reading and near work.NeverSeldomOccasionallyFrequentlyAlwaysI leave out small words when reading.NeverSeldomOccasionallyFrequentlyAlwaysI write uphill or downhill (my handwriting tends to slant up or down).NeverSeldomOccasionallyFrequentlyAlwaysColumns of numbers appear misaligned.NeverSeldomOccasionallyFrequentlyAlwaysI don't understand what I read.NeverSeldomOccasionallyFrequentlyAlwaysI am poor in sports.NeverSeldomOccasionallyFrequentlyAlwaysI hold my reading very close.NeverSeldomOccasionallyFrequentlyAlwaysI have trouble keeping attention on reading.NeverSeldomOccasionallyFrequentlyAlwaysI have difficulty completing assignments on time.NeverSeldomOccasionallyFrequentlyAlwaysI often say "I can't" before trying.NeverSeldomOccasionallyFrequentlyAlwaysI avoid sports and games.NeverSeldomOccasionallyFrequentlyAlwaysI have poor hand/eye coordination.NeverSeldomOccasionallyFrequentlyAlwaysI do not judge distance accurately.NeverSeldomOccasionallyFrequentlyAlwaysI am clumsy.NeverSeldomOccasionallyFrequentlyAlwaysI do not use my time well.NeverSeldomOccasionallyFrequentlyAlwaysI do not do well figuring out change (money).NeverSeldomOccasionallyFrequentlyAlwaysI lose papers and belongings.NeverSeldomOccasionallyFrequentlyAlwaysI have trouble with car/motion sickness.NeverSeldomOccasionallyFrequentlyAlwaysI am forgetful with a poor memory.NeverSeldomOccasionallyFrequentlyAlways