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 _______________*