Please assign a frequency for each symptom below.

1. Blurred vision at near*

2. Double vision*

3. Headaches associated with near work*

4. Words run together when reading*

5. Burning, stinging, watery eyes*

6. Falling asleep when reading*

7. Vision worse at the end of the day*

8. Skipping or repeating lines when reading*

9. Dizziness or nausea associated with near work*

10. Head tilt or closing one eye when reading*

11. Difficulty copying from the chalkboard*

12. Avoidance of reading and near work*

13. Omitting small words when reading*

14. Writing uphill or downhill*

15. Mis-aligning digits in columns of numbers*

16. Reading comprehension declining over time*

17. Inconsistent / poor sports performance*

18. Holding reading material too close*

19. Short attention span*

20. Difficulty completing assignments in reasonable time*

21. Saying "I can't" before trying*

22. Avoiding sports and games*

23. Difficulty with hand tools - scissors, calculator, keys, etc.*

24. Inability to estimate distances accurately*

25. Tendency to knock things over on desk or table*

26. Difficulty with time management*

27. Difficulty with money concepts, making change*

28. Misplaces or loses papers, objects, belongings*

29. Car sickness / motion sickness*

30. Forgetful, poor memory*

Functional Vision Lifestyle Checklist