Vision Quiz

COVD Quality of Life Checklist

To take the vision quiz, check the column which best represents the occurrence of each symptom.

Category	Symptom	Never	Seldom	Occas.	Freq.	Always
A	Blur when looking at near
A	Headaches with near work
A	Sees worse at end of the day
A	Difficulty copying from the Chalkboard
A	Avoids near work/reading
A	Holds head too close to the page
B	Has double vision
B	Words run together while reading
B	Eyes burn, itch, or seem watery
B	Falls asleep while reading
B	Closes one eye or tilts head while reading
OR	Dizzy or nauseous with near work
OR	Writes up or down hill
OR	Poor/inconsistent in sports
OR	Avoids sports/games
OR	Poor hand-eye coordination/poor handwriting
OR	Clumsy/knocks things over
OR	Car/motion sickness
OM	Skips or repeats lines when reading
OM	Misaligns digits/columns of numbers
P	Reading comprehension is poor
P	Trouble keeping attention on reading
P	Says “I can’t” before trying
P	Does not use his/her time well
P	Does not make change well with money
P	Loses belongings/things
P	Forgetful/poor memory
ALL	Difficulty completing assignments on time
ALL	Does not judge distance accurately

Your Final Score:

Score >20 — There is a high risk of having a vision problem that makes it difficult to read, to learn, to comprehend and even to pay attention. Further evaluation with a Comprehensive Vision Examination is recommended.