Functional Vision Lifestyle Checklist Date Name First Last PRE-VTPOST-VT Please remember to complete the pre-VT survey as well. Click here for the Pre-VT SurveyPlease assign a frequency for each symptom below.1. Blurred vision at near*Never or non-existentSeldomOccasionallyFrequentlyAlways2. Double vision*Never or non-existentSeldomOccasionallyFrequentlyAlways3. Headaches associated with near work*Never or non-existentSeldomOccasionallyFrequentlyAlways4. Words run together when reading*Never or non-existentSeldomOccasionallyFrequentlyAlways5. Burning, stinging, watery eyes*Never or non-existentSeldomOccasionallyFrequentlyAlways6. Falling asleep when reading*Never or non-existentSeldomOccasionallyFrequentlyAlways7. Vision worse at the end of the day*Never or non-existentSeldomOccasionallyFrequentlyAlways8. Skipping or repeating lines when reading*Never or non-existentSeldomOccasionallyFrequentlyAlways9. Dizziness or nausea associated with near work*Never or non-existentSeldomOccasionallyFrequentlyAlways10. Head tilt or closing one eye when reading*Never or non-existentSeldomOccasionallyFrequentlyAlways11. Difficulty copying from the chalkboard*Never or non-existentSeldomOccasionallyFrequentlyAlways12. Avoidance of reading and near work*Never or non-existentSeldomOccasionallyFrequentlyAlways13. Omitting small words when reading*Never or non-existentSeldomOccasionallyFrequentlyAlways14. Writing uphill or downhill*Never or non-existentSeldomOccasionallyFrequentlyAlways15. Mis-aligning digits in columns of numbers*Never or non-existentSeldomOccasionallyFrequentlyAlways16. Reading comprehension declining over time*Never or non-existentSeldomOccasionallyFrequentlyAlways17. Inconsistent / poor sports performance*Never or non-existentSeldomOccasionallyFrequentlyAlways18. Holding reading material too close*Never or non-existentSeldomOccasionallyFrequentlyAlways19. Short attention span*Never or non-existentSeldomOccasionallyFrequentlyAlways20. Difficulty completing assignments in reasonable time*Never or non-existentSeldomOccasionallyFrequentlyAlways21. Saying "I can't" before trying*Never or non-existentSeldomOccasionallyFrequentlyAlways22. Avoiding sports and games*Never or non-existentSeldomOccasionallyFrequentlyAlways23. Difficulty with hand tools - scissors, calculator, keys, etc.*Never or non-existentSeldomOccasionallyFrequentlyAlways24. Inability to estimate distances accurately*Never or non-existentSeldomOccasionallyFrequentlyAlways25. Tendency to knock things over on desk or table*Never or non-existentSeldomOccasionallyFrequentlyAlways26. Difficulty with time management*Never or non-existentSeldomOccasionallyFrequentlyAlways27. Difficulty with money concepts, making change*Never or non-existentSeldomOccasionallyFrequentlyAlways28. Misplaces or loses papers, objects, belongings*Never or non-existentSeldomOccasionallyFrequentlyAlways29. Car sickness / motion sickness*Never or non-existentSeldomOccasionallyFrequentlyAlways30. Forgetful, poor memory*Never or non-existentSeldomOccasionallyFrequentlyAlways
