Symptom Survey

Children's Symptom Survey

Children's Survey Checklist

Any of the following symptoms may indicate a functional vision problem. Please make note of the symptoms that occur and score 1 point for each one your child relates to.
If you would like to request an evaluation, please make note of your score as you will need this when making an appointment.


A. Signs of possible EYE FOCUS problems:

Complains of blurred vision
Difficulty shifting focus repeatedly from far to near
Complains of eyestrain, sore or "burning" eyes after a time on task
Complains of headaches
Excessive rubbing of eyes
Inattention to visual details
Poor reading comprehension gets worse over time on task
Head very close to book when reading/writing
Excessively blinking during visual tasks
Squints when focusing on smaller print
Reads very slowly
Notice vision blurs at distance when looking up from near work
Eyes are bothered by light/glare

B. Signs of possible EYE TRACKING problems:

Loses place often when reading/copying
Skips or re-reads words, letters or lines
Must use finger to keep place
Poor reading comprehension
Short attention span
Moves head excessively when reading
Notice that letters or lines "run together" or words "jump" when reading
Have difficulty tracking moving objects
Dislikes tasks requiring sustained concentration

C. Signs of possible EYE TEAMING problems:

Covers or closes one eye when reading
Rubs eyes
Complains of eye strain
Complains of headaches
Complains of words moving/floating on page
Reading comprehension reduces over time
Clumsy and/or poor ball skills
Unusual head turn or body posture when reading and/or writing


1. Signs of a possible VISUAL-SPATIAL dysfunction:

Poor athletic performance
Lack of coordination and balance
Clumsy, falls, bumps into things often
Both sides of body don't tend to work together
Difficulty knowing right for left
Reverses letters and numbers when writing
Writes from right to left of page
Tend to lose awareness of surroundings when concentrating
Having difficulty with sports involving good hand-eye co-ordination
Experience car sickness

2. Signs of possible VISUAL ANALYSIS dysfunction:

Difficulty learning alphabet and sight words
Difficulty learning moths concepts of size, magnitude and position
Confuses likeness and minor differences
Mistakes words with similar beginnings
Difficulty recognizing letters, shapes
Difficulty distinguishing main idea from minor detail
Overgeneralises when classifying objects

3. Signs of possible VISUAL-MOTOR dysfunction:

Difficulty copying from the board
Sloppy drawing and/or writing skills
Poor spacing/inability to stay on lines
Erases excessively
Can respond well orally but poorly in writing
Slow to complete written assignments
Knows the material but does poorly in tests
Difficulty writing numbers in columns for math's problems

4. Signs of possible VISUAL-AUDITORY dysfunction:

Slow learning to match colours to colour names
Slow learning to match shapes to shape names
Slow learning to match letters and numbers to their names
Difficulty with rhythmic activities
Poor spelling ability
Difficulty learning to read phonetically
Difficulty relating to symbols to their relevant sounds

Total Score

Print this survey

Many children do not realise that their struggles in the classroom are in no way linked to intelligence or how hard they are trying, instead they are not able to visually process the information put before them. These types of vision problems are called Functional Vision Disorders or Visual Dysfunction.

If you child has scored 5 or more on the survey above then we recommend a comprehensive eye examination with our Behavioural Optometrist

Contact us for more information or to request an appointment