Visual Skills Symptom Survey

There are many signs and symptoms of visual deficits. Adults are better at noticing and verbalizing complaints such as headaches, double vision, and visual discomfort and fatigue. Children may more often exhibit signs such as poor recall for reading, body tension and squirming/wiggling while doing near work, covering one eye, and turning his or her head to one side while attempting to read. Poor or erratic school engagement, and even sub-par sports performance, may indicate a vision problem.

The following is a questionnaire that you may print and fill out for yourself, with a student, or with your child. It is based upon a symptom survey designed, studied, revised and published by a group of leading optometrists. There is a strong correlation between exhibiting many of these symptoms and the diagnosis of visual skill deficits, a leading cause of visually-related learning difficulties.

Please fill out the webform to learn you or your child’s symptom score. This form is not secure. You should not use this information to diagnose or treat any eye problems, health problems, or illnesses without consulting your pediatrician, family doctor, or optometrist.

A score of 16 or higher for a child, 21 or higher for an adult is highly correlated with visual skills problems (although many vision problems are relatively asymptomatic and would be missed by this survey).

You may print it out and bring it with you to your exam.

Visual Skills Symptoms Survey

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  • Please answer the following questions about how your eyes feel when reading or doing close work.

    0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Enter one of the following numbers: 0 - Never 1 - Infrequently 2 - Sometimes 3 - Fairly Often 4 - Always
  • Consider referral for a Visual Efficiency Exam if total score is 16 or higher for kids, 22 for adults.

  • This field is for validation purposes and should be left unchanged.