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Quality of Life Survey - Symptom Severity

This survey will help evaluate how severe you feel your symptoms are and if you should be seeking the assistance of a Developmental Optometrist. Survey questions adopted from the College of Optometrists in Vision Development. [https://www.covd.org]

 

1 / 31

Blurred close vision

2 / 31

Double vision

3 / 31

Headaches with near work

4 / 31

Words run together reading

5 / 31

Burning, itchy, watery eyes

6 / 31

Falls asleep reading

7 / 31

Sees worse at the end of day

8 / 31

Skips / repeats lines reading

9 / 31

Dizzy / nauseated by near work

10 / 31

Head tilt / one eye closed to read

11 / 31

Difficulty copying from chalkboard

12 / 31

Avoids near work / reading

13 / 31

Omits small words when reading

14 / 31

Writes uphill / downhill

15 / 31

Misaligns digits / columns of numbers

16 / 31

Poor reading comprehension

17 / 31

Poor / inconsistent in sports

18 / 31

Holds reading too close

19 / 31

Trouble keeping attention on reading

20 / 31

Difficulty completing work on time

21 / 31

Says "I can't before trying"

22 / 31

Avoids sports / games

23 / 31

Poor hand / eye coordination

24 / 31

Poor handwriting

25 / 31

Does not judge distance accurately

26 / 31

Clumsy, knocks things over

27 / 31

Poor time use / management

28 / 31

Does not make change well

29 / 31

Loses things / belongings

30 / 31

Car or motion sickness

31 / 31

Forgetfulness / poor memory

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