Functional Vision Lifestyle Checklist Date MM slash DD slash YYYY Name First Last PRE-VT POST-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-existent Seldom Occasionally Frequently Always 2. Double vision* Never or non-existent Seldom Occasionally Frequently Always 3. Headaches associated with near work* Never or non-existent Seldom Occasionally Frequently Always 4. Words run together when reading* Never or non-existent Seldom Occasionally Frequently Always 5. Burning, stinging, watery eyes* Never or non-existent Seldom Occasionally Frequently Always 6. Falling asleep when reading* Never or non-existent Seldom Occasionally Frequently Always 7. Vision worse at the end of the day* Never or non-existent Seldom Occasionally Frequently Always 8. Skipping or repeating lines when reading* Never or non-existent Seldom Occasionally Frequently Always 9. Dizziness or nausea associated with near work* Never or non-existent Seldom Occasionally Frequently Always 10. Head tilt or closing one eye when reading* Never or non-existent Seldom Occasionally Frequently Always 11. Difficulty copying from the chalkboard* Never or non-existent Seldom Occasionally Frequently Always 12. Avoidance of reading and near work* Never or non-existent Seldom Occasionally Frequently Always 13. Omitting small words when reading* Never or non-existent Seldom Occasionally Frequently Always 14. Writing uphill or downhill* Never or non-existent Seldom Occasionally Frequently Always 15. Mis-aligning digits in columns of numbers* Never or non-existent Seldom Occasionally Frequently Always 16. Reading comprehension declining over time* Never or non-existent Seldom Occasionally Frequently Always 17. Inconsistent / poor sports performance* Never or non-existent Seldom Occasionally Frequently Always 18. Holding reading material too close* Never or non-existent Seldom Occasionally Frequently Always 19. Short attention span* Never or non-existent Seldom Occasionally Frequently Always 20. Difficulty completing assignments in reasonable time* Never or non-existent Seldom Occasionally Frequently Always 21. Saying "I can't" before trying* Never or non-existent Seldom Occasionally Frequently Always 22. Avoiding sports and games* Never or non-existent Seldom Occasionally Frequently Always 23. Difficulty with hand tools - scissors, calculator, keys, etc.* Never or non-existent Seldom Occasionally Frequently Always 24. Inability to estimate distances accurately* Never or non-existent Seldom Occasionally Frequently Always 25. Tendency to knock things over on desk or table* Never or non-existent Seldom Occasionally Frequently Always 26. Difficulty with time management* Never or non-existent Seldom Occasionally Frequently Always 27. Difficulty with money concepts, making change* Never or non-existent Seldom Occasionally Frequently Always 28. Misplaces or loses papers, objects, belongings* Never or non-existent Seldom Occasionally Frequently Always 29. Car sickness / motion sickness* Never or non-existent Seldom Occasionally Frequently Always 30. Forgetful, poor memory* Never or non-existent Seldom Occasionally Frequently Always
Appointment times may vary so call us for availability.