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Visual Skills Questionnaire

Individuals who lack the necessary visual skills for effective reading, writing, and learning (i.e., eye movement and focusing skills, convergence, eye-hand activity, visual memory skills, etc) will often demonstrate the signs and symptoms listed on this simple questionnaire.

Please answer the following questions about the person that may have learning or vision problem. After answering all of the questions, click the "Quick Assessment" button for scoring and recommendations.

How often does he/she experience:		Never	Seldom	Sometimes	Often	Always
1.)	Headaches with near (close up) work
2.)	Words running together while reading
3.)	Burning, itching, or watery eyes
4.)	Skipping or repeating lines while reading
5.)	Tilting head or closing one eye when reading
6.)	Difficulty copying from the chalkboard
7.)	Avoiding reading or near (close up) work
8.)	Omitting small words when reading
9.)	Writing on a slant (up/down hill)
10.)	Misaligning digits or columns of numbers
11.)	Poor reading comprehension
12.)	Holding reading too close
13.)	Trouble keeping attention on reading
14.)	Difficulty completing assignments on time
15.)	Saying "I can't" before even trying
16.)	Being Clumsy or knocking things over
17.)	Not using his/her time well
18.)	Losing belongings/things
19.)	Forgetful/poor memory

DISCLAIMER: This questionnaire is for informational purposes only, it is not intended to replace the services of an optometrist or eye doctor.

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