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Do you experience eyestrain and headaches after reading for a short period of time?: Yes: No:
Do you find it difficult to concentrate when reading? : Yes: No:
Do you often have a short attention span?: Yes: No:
Do you frequently lose your place when reading?: Yes: No:
Do you skip or re-read lines when reading?: Yes: No:
Do you tilt your head to one side when reading?: Yes: No:
Do you close or cover one eye when reading?: Yes: No:
Do you rub your eyes often?: Yes: No:
Do you find the words moving on the page in front of you?: Yes: No:
Do you screw up your eyes or blink excessively?: Yes: No:
Do you read with the book very close to your eyes?: Yes: No:
Do you have trouble copying from the board, and make more mistakes than you think you should?: Yes: No:
Do you avoid reading?: Yes: No:
Do you write up or down hill?: Yes: No:
Is your vision worse at the end of the day?: Yes: No:
Do you repeatedly confuse the left and the right?: Yes: No:
Do you often appear awkward and clumsy when climbing, throwing, or participating in other sports activities?: Yes: No:
Do you suffer from car sickness?: Yes: No:
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