Physical Complaints

1.

Headaches when reading or doing desk work.

0

1

2

3**

4**

2.

Car sickness.

0

1

2

3**

4**

3.

Upset stomach during reading or school work.

0

1

2

3**

4**

4.

Exhausted after a day at school.

0

1

2

3**

4**

5.

Complains of blurred vision even though the screenings at the school or pediatrician's office have been normal, or a routine eye examination has been normal.

0

1

2

3**

4**

6.

Eyestrain during reading or desk work.

0

1

2

3**

4**

7.

When reading, sees the print dance.

0

1

2

3**

4**

8.

When reading, sees the print run together.

0

1

2**

3**

4**

9.

Complains that the print is too small.

0

1

2

3**

4**

10.

Sees two of things when only one is there.

0

1

2**

3**

4**

11.

Covers an eye when trying to read.

0

1

2

3**

4**

12.

Tilts and turns head to side to ignore one eye when reading, writing or watching TV.

0

1

2

3**

4**

13.

Squints when looking from near to far or from far to near.

0

1

2

3**

4**

14.

Rubs eyes when reading.

0

1

2

3**

4**

15.

Holds book too closely; face too close to desk surface.

0

1

2

3**

4**

16.

Moves closer and further away from book, as if to "focus" it.

0

1

2

3**

4**

17.

One eye turns in or out.

0

1**

2**

3**

4**

18.

Your child has already been diagnosed with a Lazy Eye (amblyopia).

0

1**

2**

3**

4**

19.

Your child had surgery for a crossed eye but still has problems with either school or coordination.

0

1**

2**

3**

4**

Physical Complaints Section Score

_______________________

Learning-to-Read

20.

Very slow at sounding out words even when the "rules" are known; i.e., knows the letter sounds for "c," "a," and "t," but labors to sound out "cat."

0

1

2

3

4

21.

Omits small words.

0

1

2

3

4

22.

Repeats letters or syllables in a word.

0

1

2

3

4

23.

Reads the first letter or two of the word and guesses at the rest.

0

1

2

3

4

24.

Fails to recognize same word in the next line.

0

1

2

3

4

25.

Can read a word that is isolated and large on a flash card, but can't recognize the same word when it's smaller or squeezed into a line of print.

0

1

2

3

4

26.

Confuses likenesses and minor differences, such as substituting "what" for "that."

0

1

2

3

4

27.

Reverses letters or words, such as "b" for "d" or "was" for "saw."

0

1

2

3

4

28.

Needs to use a finger to maintain place when reading.

0

1

2

3

4

29.

Get's lost when trying to sound out words of more than one syllable.

0

1

2

3

4

30.

Reading improves if you use a pickup stick or pen tip to point to the parts of the words for your child, reducing the need for accurate eye control.

0

1

2

3

4

Learning-to-Read Section Score

_______________________

Reading-to-Learn

31.

Reads well for a short time then begins to make careless errors.

0

1

2

3

4

32.

Rapidly tires out and loses comprehension when reading.

0

1

2

3

4

33.

Whispers to self while reading silently so the words can go in "through the ears."

0

1

2

3

4

34.

Your child can sound out or recognize the words but his comprehension is better when he uses his ears to listen to you read than when he uses his eyes to read himself.

0

1

2

3

4

35.

Avoids reading whenever possible.

0

1

2

3

4

36.

Reading comprehension is not as good as your child's intelligence would predict.

0

1

2

3

4

37.

Will not attempt books with smaller print.

0

1

2

3

4

38.

Loves to be read to, but will not read himself.

0

1

2

3

4

39.

Enjoys buying books, but never reads them.

0

1

2

3

4

40.

Takes forever to finish a book, even when interested.

0

1

2

3

4

41.

Counts pages before considering a book.

0

1

2

3

4

42.

Your child's reads well, but reading skills don't reflect his/her intelligence and potential.

0

1

2

3

4

Reading-to-Learn Section Score

_______________________

Getting It on Paper

43.

Makes errors in copying from desk to paper.

0

1

2

3

4

44.

Copying assignments takes forever.

0

1

2

3

4

45.

Handwriting is off the lines, going "up and down hill."

0

1

2

3

4

46.

When writing, words are poorly spaced.

0

1

2

3

4

47.

Your child is bright and reads well but struggles to get thoughts down on paper.

0

1

2

3

4

48.

In math, misaligns digits or columns.

0

1

2

3

4

49.

Copies words backwards; for example, was for saw.

0

1

2

3

4

50.

Confuses bs and ds.

0

1

2

3

4

51.

In math, becomes confused if there are too many problems on the same page.

0

1

2

3

4

52.

Can spell out loud but not when having to write the words.

0

1

2

3

4

53.

Makes errors when copying from reference book to notebook.

0

1

2

3

4

54.

Brain moves faster than hands. Your child is bright, but his/her hands are not.

0

1

2

3

4

55.

Leaves out letters or words when copying.

0

1

2

3

4

56.

When writing, can't spell the same words that were known on the spelling test.

0

1

2

3

4

57.

Spells words like they sound rather than correctly.

0

1

2

3

4

Getting it on Paper Section Score

_______________________

Coordination and Sports
(If a question applies to a sport you don't play, give yourself a score of 0 )

58.

Runs into things.

0

1

2

3

4

59.

Stumbles, trips or falls.

0

1

2

3

4

60.

Clumsy. Poor balance.

0

1

2

3

4

61.

Awkward when moving.

0

1

2

3

4

62.

Has/had difficulty in learning to ride a bike.

0

1

2

3

4

63.

Knocks things over.

0

1

2

3

4

64.

Can't keep eye on the ball.

0

1

2

3

4

65.

Catches "by feel," trying to grab the ball after it bounces off chest.

0

1

2

3

4

66.

Spends all time reading. Avoids exercise, especially ball sports.

0

1

2

3

4

67.

Glasses are rapidly becoming stronger.

0

1

2

3

4

68.

Can't hit a ball.

0

1

2

3

4

69.

In tennis, can't return lobbed balls.

0

1

2

3

4

70.

In baseball or softball, misjudges and runs underneath pop flies.

0

1

2

3

4

Coordination and Sports Section Score

_______________________

Driving

71.

Has difficulty judging the position of other cars.

0

1

2

3

4

72.

Follows too closely.

0

1

2

3

4

73.

Slow to respond.

0

1

2

3

4

74.

Poor at parallel parking.

0

1

2

3

4

75.

Has to be overly cautious.

0

1

2

3

4

76.

Becomes apprehensive if asked to drive at night.

0

1

2

3

4

Driving Section Score

_______________________

Attention

77.

Attention much better when using ears to listen than when using eyes to read.

0

1

2

3

4

78.

Attention is good for math (except for story problems) but poor for reading.

0

1

2

3

4

79.

Homework is a battle.

0

1

2

3

4

80.

During reading and homework there comes a point after which it does no good to push any further. Your child "shuts down."

0

1

2

3

4

81.

The longer your child uses eyes for reading or writing, the greater the frustration and fidgeting become.

0

1

2

3

4

82.

Assignments aren't completed in school and have to be brought home.

0

1

2

3

4

83.

Your child can't "stay on task" when reading or writing.

0

1

2

3

4

84.

Needs to put his/her hands on everything. Information from eyes alone isn't enough.

0

1

2

3

4

85.

Has to work to sit in a chair, seems to be constantly readjusting balance.

0

1

2

3

4

86.

Has the same reading struggles whether on or off medication.

0

1

2

3

4

87.

"Attention" problems develop when schoolwork or reading is mentioned. Attention is fine for "hands on" mechanical type activities.

0

1

2

3

4

Attention Section Score

_______________________

Behavior, Self Esteem, Relationships

88.

Your child feels stupid.

0

1

2

3

4

89.

Self-confidence is low, attitude is poor.

0

1

2

3

4

90.

Your child is either worn out or angry when coming home from school.

0

1

2

3

4

91.

Your child's poor eye contact makes others assume your child isn't listening.

0

1

2

3

4

92.

You child is unhappy or withdrawn.

0

1

2

3

4

93.

Your child has books rather than friends.

0

1

2

3

4

94.

In school your child is ridiculed by other students or the teacher.

0

1

2

3

4

95.

Your child's frustration in school seems to trigger behavior problems.

0

1

2

3

4

96.

Homework ends up with you angry and your child crying.

0

1

2

3

4

97.

In sports, your child is left sitting on the bench. Your child isn't asked to participate.

0

1

2

3

4

98.

Your child's struggle with schoolwork affects the whole family.

0

1

2

3

4

99.

Your child's school performance could limit future educational and job opportunities.

0

1

2

3

4

100.

Grades are good but your child isn't working up to potential and the whole family feels the frustration.

0

1

2

3

4

Behavior, Self Esteem, Relationships Section Score

_______________________

Scoring Your Child's Results

Physical Complaints Section Score

_______________________

Learning to Read Section Score

_______________________

Reading to Learn Section Score

_______________________

Getting it on Paper Section Score

_______________________

Coordination and Sports Section Score

_______________________

Driving Section Score

_______________________

Attention Section Score

_______________________

Behavior, Self Esteem, Relationships Section Score

_______________________

Total

_______________________

How did your child do?

0 to 10:

Excellent

11 to 20:

Good, but certainly room for improvement

21 to 30:

Suspicious, you should consider a developmental vision evaluation for your child.

31 or more:

A developmental vision evaluation is definitely indicated.

Call us at (321) 253-2020