ADULT SELF ASSESSMENT The following assessment is adapted from Dr. Cook's most recent book, VISUAL FITNESS: 7 Minutes to Better Eyesight and Beyond. If you are really interested in learning how vision may be affecting your life in ways you never imagined, print this out and score yourself on 90 statements that are related to problems with the "7 Visual Abilities." As you rate yourself, use the following five-point scale: 0—The statement NEVER applies. 1—The statement SELDOM applies. 2—The statement OCCASIONALLY applies. 3—The statement FREQUENTLY applies. 4—The statement ALWAYS applies. Print out this questionnaire and use the following rating scale to score your visual performance.   Read each statement and circle the number that best describes your experience. If you wear glasses, consider the statements as if you were wearing your glasses. For instance, if the statement is, "Does the print blur when you are reading?" consider only those times blurring occurred while you were wearing your reading glasses, not when you had your glasses off. When you complete each section, add up your scores for that section. General (If you don't wear glasses, give yourself a score of 0 next to the questions which ask about glasses.) 1. Things are blurry for a moment when you look up from reading or computer work. 0 1 2 3 4 2. You get headaches or eyestrain when you use your eyes for careful seeing. 0 1 2 3 4 3. Your stomach gets upset after you use your eyes. 0 1 2 3 4 4. Things blur in and out of focus. 0 1 2 3 4 5. It makes you nervous to search the crowded shelves in the grocery store. 0 1 2 3 4 6. Your glasses give you headaches or eyestrain even though you need them to see. 0 1 2 3 4 7. Your glasses make you sick to your stomach. 0 1 2 3 4 8. Since you started wearing glasses you find yourself avoiding reading. 0 1 2 3 4 9. Your glasses keep getting stronger. 0 1 2 3 4 10. You would like to become less dependent on glasses 0 1 2 3 4 11. You have glasses, but avoid wearing them as often as possible. 0 1 2 3 4 12. Your eye drifts in toward your nose or out toward your ear. 0 1 2 3 4 13. For an eye that drifts, you have had surgery the following number of times. 0 1 2 3 4 14. At night, you have difficulty falling asleep. 0 1 2 3 4 General Section Score _______________________   Reading 15. When you read, the print blurs. 0 1 2 3 4 16. When you read, the print runs together. 0 1 2 3 4 17. When you read, the print looks unsteady or dances. 0 1 2 3 4 18. Reading gives you eye strain or headaches 0 1 2 3 4 19. Reading puts you to sleep. 0 1 2 3 4 20. You avoid reading for fun. 0 1 2 3 4 21. You avoid longer books. 0 1 2 3 4 22. You avoid books with smaller print. 0 1 2 3 4 23. When you read, you get the feeling that you'd rather be somewhere else. 0 1 2 3 4 24. You rapidly fatigue and lose comprehension when reading. 0 1 2 3 4 25. You have to whisper to yourself when reading. 0 1 2 3 4 26. Reading gives you an upset stomach. 0 1 2 3 4 27. You lose your place and skip or reread lines. 0 1 2 3 4 28. You're afraid to read out loud in front of other people. 0 1 2 3 4 29. Reading takes too much effort. 0 1 2 3 4 30. You read, "One . . . word . . . at . . . a . . . time." 0 1 2 3 4 31. You have to reread sentences to understand what you are reading. 0 1 2 3 4 Reading Section Score _______________________   Driving 32. You get eyestrain or headaches when you drive. 0 1 2 3 4 33. You get carsick, especially when sitting in the back seat. 0 1 2 3 4 34. You rapidly fatigue when driving. 0 1 2 3 4 35. You dislike driving at night. 0 1 2 3 4 36. You have difficulty judging how far away other cars are. 0 1 2 3 4 37. You find parallel parking difficult. 0 1 2 3 4 38. You have to look twice because you can't trust yourself to see things correctly the first time. 0 1 2 3 4 39. You have difficulty telling how fast other cars are moving. 0 1 2 3 4 40. You have trouble seeing road signs. 0 1 2 3 4 41. It makes you nervous to drive when traffic is heavy. 0 1 2 3 4 42. It makes you nervous to drive on the freeway. 0 1 2 3 4 43. At night, the tail lights ahead of you seem to double up. 0 1 2 3 4 44. You get lost easily when driving. 0 1 2 3 4 45. Your worries about driving limit your activities. 0 1 2 3 4 Driving Section Score _______________________   Work 46. You have more trouble with computer and desk work as the day goes on. 0 1 2 3 4 47. You have to schedule your computer and desk work in the morning when you're fresh. 0 1 2 3 4 48. Your productivity goes down as the day progresses. 0 1 2 3 4 49. You get eyestrain or headaches during computer or desk work. 0 1 2 3 4 50. Your stomach gets upset during computer or desk work. 0 1 2 3 4 51. You reverse numbers at work, such as seeing 36 for 63. 0 1 2 3 4 52. You have to check your work for errors constantly because your eyes play tricks on you. 0 1 2 3 4 53. Your computer or desk work takes longer than it should. 0 1 2 3 4 54. You put off your desk work and instead spend your time talking, either face to face or on the phone. 0 1 2 3 4 55. You'd have second thoughts about a promotion if it meant more reading or desk work. 0 1 2 3 4 Work Section Score _______________________   Sports (If a question applies to a sport you don't play, give yourself a score of 0 ) 56. When you exercise, you prefer walking, running, swimming, calisthenics, or lifting weights rather than visual activities such as baseball, tennis or golf. 0 1 2 3 4 57. When it comes to ball sports, you're a klutz. 0 1 2 3 4 58. You've always avoided participating in ball sports. 0 1 2 3 4 59. It's hard to catch or hit a ball. 0 1 2 3 4 60. When playing golf, your short game is more difficult. 0 1 2 3 4 61. When playing golf, it's not easy to read the green. 0 1 2 3 4 62. When playing golf or tennis, you hit long or short. 0 1 2 3 4 63. In whatever ball sport you play, it's harder to maintain your concentration the longer the game continues. 0 1 2 3 4 64. In any ball sport, you're not as good as your technique would predict. 0 1 2 3 4 65. In tennis you have trouble with returning lobbed shots. 0 1 2 3 4 66. In tennis, you have more difficulty at the net than at the baseline. 0 1 2 3 4 Sports Section Score _______________________   Coordination 67. It bothers you to walk down stairs. 0 1 2 3 4 68. You bump into things. 0 1 2 3 4 69. When dancing, you have two left feet. 0 1 2 3 4 70. It makes you nervous to walk in a crowd. 0 1 2 3 4 71. You feel clumsy. 0 1 2 3 4 72. You trip and stumble if you're not careful. 0 1 2 3 4 Coordination Section Score _______________________   Relationships 73. You have trouble maintaining eye contact when speaking to someone. 0 1 2 3 4 74. You feel like backing further away when a person is speaking to you. 0 1 2 3 4 75. You feel as if you need to move right up next to people when they are talking to you. 0 1 2 3 4 76. You are too tired to enjoy your friends or family after a day of using your eyes. 0 1 2 3 4 77. After a day of using your eyes, you are irritable or short-tempered. 0 1 2 3 4 78. Sore eyes or headaches interfere with your relationships. 0 1 2 3 4 79. Desk work drags on forever so you have little time left to enjoy your friends or family. 0 1 2 3 4 80. The effort it takes you to read has kept you from going back to school and is therefore limiting your income. 0 1 2 3 4 81. Your worries about driving limits the number of activities in which you or your children get to participate. 0 1 2 3 4 82. Your reading ability affects your confidence. 0 1 2 3 4 83. Your driving ability affects your confidence. 0 1 2 3 4 84. Your coordination affects your confidence. 0 1 2 3 4 85. Having to wear glasses affects your confidence 0 1 2 3 4 86. You're embarrassed to be seen in glasses 0 1 2 3 4 87. You're embarrassed by the appearance of your eye turning. 0 1 2 3 4 88. When you speak with people they don't seem to know which of your eyes to look at. 0 1 2 3 4 89. When you speak with people they look over your shoulder to see where you are looking. 0 1 2 3 4 90. When you speak to people your attention is on holding your eyes straight. 0 1 2 3 4 Relationships Section Score _______________________   Evaluating Your Self-Assessment Add together your scores from the seven sections. Reading Section Score _______________________ Driving Section Score _______________________ Work Section Score _______________________ Relationships Section Score _______________________ Sports Section Score _______________________ Coordination Section Score _______________________ General Section Score _______________________ Total _______________________   0 to 10: Excellent—Wow! 11 to 20: Good— But if you are interested in improving this, come in and see us. 21 to 40: Fair—But plenty of room for improvement - Schedule a Developmental Vision Evaluation. Greater than 40: Schedule an evaluation—yesterday! For an appointment call (321) 253-2020.