| 1. My child has difficulty concentrating and paying attention. | |||
| 1. never | 2. sometimes | 3. often | |
| 2. My child requires a lot of time to complete homework. | |||
| 1. never | 2. sometimes | 3. often | |
| 3. My child complains of blurred vision, or double vision when reading. | |||
| 1. never | 2. sometimes | 3. often | |
| 4. My child complains of eyestrain or headaches when reading. | |||
| 1. never | 2. sometimes | 3. often | |
| 5. My child loses his/her place when reading or skips words or lines. | |||
| 1. never | 2. sometimes | 3. often | |
| 6. My child has difficulty copying from the board. | |||
| 1. never | 2. sometimes | 3. often | |
| 7. My child has difficulty with handwriting. | |||
| 1. never | 2. sometimes | 3. often | |
| 8. My child reverses letters, numbers or confuses similar words. | |||
| 1. never | 2. sometimes | 3. often | |
| 9. My child becomes tired or sleepy after short periods of time or his/her reading comprehension deteriorates with time. | |||
| 1. never | 2. sometimes | 3. often | |
| 10. My child has struggled in school. | |||
| 1. never | 2. sometimes | 3. often | |
For each question your child's score will be 1, 2, or 3.
Add up the total score for the ten questions and compare it to the guidelines below.
| Score | What That Score Means |
| 10-12 | Your child probably does not have a vision problem interfering with school performance. |
| 13-18 | Your child may have a vision problem interfering with school performance. |
| 19-30 | Your child almost certainly has a vision problem interfering with school performance. |