Vision Survey

Vision Survey

Headaches associated with near work
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Words run together when reading
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Burning, stinging, watery eyes
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Skipping or repeating lines when reading
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Head tilt or closing one eye when reading
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Difficulty copying from the chalkboard
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Avoidance of reading and near work
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Omitting small words when reading
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Writing uphill or downhill
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Mis-aligning digits in columns of numbers
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Reading comprehension declining over time
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Holding reading material too close
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Short attention span
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Difficulty completing assignments in reasonable time
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Saying "I can't" before trying
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Tendency to knock things over on desk or table
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Difficulty with time management
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Misplaces or loses papers, objects, belongings
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.
Forgetful, poor memory
Use the following scale to choose the most appropriate for each situation. It is important that you answer each question as best as you can.

Your total vision score: 0


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Score Interpretation:

A score of 20 or higher indicates that you or your child may have a symptomatic eye teamwork problem that can negatively impact school performance, reading, learning, and sports. Please note that while a score less than 20 means that the individual is not considered symptomatic, it does not mean a vision problem does not exist. Please give our office a call to schedule an evaluation to diagnose and treat the vision problems causing these symptoms. If you are curious about some symptoms you or your child are experiencing, please give us a call at (716) 434-2874.​​​​​​​


This symptom survey is derived from the National Institute of Health’s Convergence Insufficiency Treatment Trial. For full text of the study visit http://archopht.ama-assn.org/cgi/reprint/126/10/1336


​​​​​​​These surveys are not a substitute for consulting a physician and do not provide diagnoses.

Our doctors specialize in diagnosing and treating vision dysfunctions that impact school, work, sports and performance in daily activities.
​​​​​​​ This includes reading, comprehension, sustaining attention, driving and many other activities as well as behaviors.
Feel free to take the above survey to see if the symptoms you or your child are experiencing could be related to vision.
Contact us if you have questions regarding your symptoms at (716) 434-2874.