Patient Symptom Checklist And Teacher Observations printable pdf download

Patient Symptom Checklist And Teacher Observations

Patient Symptom Check List and Teacher Observations:

If your child has 20/40 vision or better and passes a vision screening at school or at the pediatrician’s office, he

or she may still have a VISION-RELATED LEARNING PROBLEM. Please indicate if your school aged child

is or has been experiencing the following symptoms:

Visual Comfort

_____ Eye(s) turned in or out at any time

AND

_____ Headaches when reading

Visual Efficiency

_____ Eyes hurt, burn, tear or itch

_____ Rubs eyes frequently when reading

_____ Get very tired after reading for a short time

_____ Avoids near work (reading, writing)

_____ Child hates to read

_____ Holds book too close to face when reading

_____ Assumes an awkward sitting position when reading

_____ Complains of seeing double or shadows

_____ Squints, closes or covers one eye when reading

_____ Uses finger or marker to keep place when reading

_____ Often loses place, skips or re-reads words/letters

_____ Reads too slowly for age/grade

_____ Slow focusing when copying from the board

_____ Sees print “running together”, “jumping” or “moving”

_____ Complains that eyes seem to be “pulling”

Visual Information

_____ School performance not up to potential

Processing

_____ Reading below grade level

Skills

_____ Reading comprehension decreases with time

Patient Symptom Checklist And Teacher Observations