Wichita Vision Development Center, (316) 722-3740

Vision and Learning Screener

Name____________________________________   Age_________   Grade_________

Teacher____________________________      School___________________________

 Quality of Life Survey  

Please put an “X” in the column that best shows how often this happens to your child.

How often does this happen?

Never

 0

A little

 1

Sometimes

 2

A  lot

 3

Always

 4

 1. Headaches with reading or writing

 

 

 

 

 

 2. Words slide together or get blurry when reading

   

 

   

   

    

 3. Reads below grade level

   

 

 

 

 

 4. Loses place while reading

 

   

   

   

 

 5. Head tilt or closes an eye when reading

         

 6. Hard to copy from the board

         

 7. Doesn’t like reading or writing

         

 8. Leaves out small words when reading

         

 9. Hard to write in a straight line

         

10. Burning, itching, or watery eyes

         

11. Hard to understand what he/she has read

         

12. Holds book very close

         

13. Hard to pay attention when reading

         

14. Hard to finish assignments on time

         

15. Gives up easily (says “I can’t” before trying)

         

16. Bumps into things, knocks things over

         

17. Homework takes too long

         

18. Daydreams

         

19. In trouble for being off task at school

         

 Number of total marks in each column

____

____

____ 

____

____ 

 Multiply total marks in each column by:

   x 0 

     x 1

  x 2

  x 3

x 4

                          Score for each column

____

____

____ 

____

____ 

                                               Total Score for all columns _______________*

 

*Total score greater than 20 indicates the child is at risk for a vision-based learning problem.  Further evaluation by a pediatric optometrist is recommended.