10-Point Scaled Symptom Survey

1. Headaches (In general including frequency and severity)

2. Eye strain, soreness, pain, or discomfort

3. Eyes get tired and generally become tired

4. Double vision, shadowing of letters, words move, jump, swim, appear to float on the page

5. Blurry Vision even though glasses are on or have been told glasses are unnecessary

6. Loss of place, skipping words and/or lines while reading, or have to reread the same line of words

7. Motor Coordination/Difficulties with Depth perception (accident prone, poor hand-eye coordination, avoid or have poor performance in sports, frequently knock things over, trip, fall, or run into things, poor rhythm/timing)

8. Academic Concerns (Poor Interest in reading and school, poor reading comprehension, poor grades, homework takes longer than it should, poor handwriting)

9. Visual Perceptual Difficulties (Letter reversals, confusion with words, letters, numbers, symbols, get lost in details, fatigues or becomes confused with too much info on page, confused with different fonts, poor visual recall)

10.Balance/Dizziness/Vertigo/Disorientation
/Nausea?

11. Poor attention, focus, concentration, hyperactivity?

12. Brain fog, sensory overstimulation, motor overload (Unable to think clearly with too much stimulus, overwhelmed with too much light, sound, busy visual environments/patterns, unable to sit still or reflexive movements due to overstimulation)

13. Behavior problems, poor self-esteem/confidence, easily frustrated, anxiety, depression

14. Eye wanders or crosses?

15. Other - please describe: (difficulty with multitasking, auditory processing difficulties, etc.)