Learning & Reading Related Issues

Patient Name
First Last
Please answer the following questions about how your eyes feel when reading or doing close work
Do your eyes feel tired when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do your eyes feel uncomfortable when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you have headaches when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you feel sleepy when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you lose concentration when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you have trouble remembering what you have read?
Never Infrequently/not very often Sometimes Fairly often Always
Do you have double vision when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you see words move, jump, swim or appear to float on the page when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you feel like you read slowly?
Never Infrequently/not very often Sometimes Fairly often Always
Do your eyes ever hurt when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you feel a "pulling" feeling around your eyes when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you notice the words blurring or coming in and out of focus when reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always
Do you lose your place while reading or doing close work?
Never Infrequently/not very often Sometimes Fairly often Always

Superior Eye Health & Vision Therapy Center