Comprehensive Eye Exam Symptom Survey

Patient Name
First Last
Please check the column that best represents the occurrence of each symptom.
Blurred vision at near
Never Seldom Occasionally Frequently Always
Double vision
Never Seldom Occasionally Frequently Always
Headaches associated with near work
Never Seldom Occasionally Frequently Always
Words run together when reading
Never Seldom Occasionally Frequently Always
Burning, stinging, watery eyes
Never Seldom Occasionally Frequently Always
Falling asleep when reading
Never Seldom Occasionally Frequently Always
Vision worse at the end of the day
Never Seldom Occasionally Frequently Always
Skipping or repeating lines when reading
Never Seldom Occasionally Frequently Always
Dizziness or nausea associated with near work
Never Seldom Occasionally Frequently Always
Head tilt or closing one eye when reading
Never Seldom Occasionally Frequently Always
Difficulty copying from the chalkboard
Never Seldom Occasionally Frequently Always
Avoidance of reading and near work
Never Seldom Occasionally Frequently Always
Omitting small words when reading
Never Seldom Occasionally Frequently Always
Writing uphill or downhill
Never Seldom Occasionally Frequently Always
Misaligning digits in columns of numbers
Never Seldom Occasionally Frequently Always
Reading comprehension declining over time
Never Seldom Occasionally Frequently Always
Inconsistent/poor sports performance
Never Seldom Occasionally Frequently Always
Holding reading material too close
Never Seldom Occasionally Frequently Always
Short attention span
Never Seldom Occasionally Frequently Always
Difficulty completing assignments in reasonable time
Never Seldom Occasionally Frequently Always
Saying "I can't" before trying
Never Seldom Occasionally Frequently Always
Avoiding sports and games
Never Seldom Occasionally Frequently Always
Difficulty with hand tools-scissors, screwdriver, calculator, keys
Never Seldom Occasionally Frequently Always
Inability to estimate distances accurately
Never Seldom Occasionally Frequently Always
Tendency to knock things over on desk or table
Never Seldom Occasionally Frequently Always
Difficulty with time management
Never Seldom Occasionally Frequently Always
Difficulty with money concepts, making change
Never Seldom Occasionally Frequently Always
Misplaces or loses papers, objects, belongings
Never Seldom Occasionally Frequently Always
Car sickness/motion sickness
Never Seldom Occasionally Frequently Always
Forgetful, poor memory
Never Seldom Occasionally Frequently Always

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