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Conditions We Treat
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Vision Symptom Checklist

Click on either the Adult or Child Symptom Checklist below to send your information to our office for review.

young-girl-winking-one-eye

Adult Symptom Checklist

Child Symptom Checklist

Adult Symptom Checklist

First name *

Phone

Email *

Eye strain or pain *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Eye fatigue or eye rubbing *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Blurry vision at near or far distance *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Double vision *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Headache after visual task *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Dizziness or nausea after visual task *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Light sensitivity *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Poor depth perception *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Bumps into objects/clumsiness *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Can't tolerate "visually-busy" places *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Uncomfortable while driving/riding in the car *

Never (0)
Seldom (1)
Occaisonally (2)
Frequently (3)
Always (4)

Head tilt or unsteady gait *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Closing one eye to see comfortably *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Skipping words or lines while reading *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Cannot read as long as you would like *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Poor reading comprehension or slow reading speed *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Poor memory *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Decreased ability to participate in hobbies/sports *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Score 15-20: Borderline vision problem.
Score 20+: vision problem is likely. Functional Vision Evaluation is recommended.

Child Symptom Checklist

Your name *

Child's first name *

Phone

Email *

Blurred vision at near ("Do the letters get fuzzy when they are small?") *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Double vision ("Do things ever split into two? Even for a second?") *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Headaches associated with near work *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Painful, sore, or watery eyes *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Gets tired when reading *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Vision worse at the end of the day *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Words run together when reading or move on the page *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Skipping or repeating lines when reading *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Omitting small words when reading *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Avoidance of reading or near work *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Dizziness or nausea associated with near work *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Head tilted or turned *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Closing one eye when reading *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Difficulty copying from chalkboard *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Reversal of letters like b's, d's, p's and q's *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Misaligning digits in columns of numbers *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Poor handwriting, writing uphill or downhill *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Reading comprehension declines over time *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Holds reading material too close *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Difficulty reading for as long as expected/desired *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Short attention span *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Difficulty completing assignments in reasonable time *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Inconsistent or poor sports performance *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Avoiding sports and games *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Poor sense of space, knocks things over, clumsy *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Car sickness or motion sickness *

Never (0)
Seldom (1)
Occasionally (2)
Frequently (3)
Always (4)

Score 15-20: Borderline vision problem.
Score: 20+: Vision problem is likely. Functional Vision Evaluation recommended.

Denver Vision Therapy, P.C.

1450 Hoyt St
Lakewood, CO 80215
P: 303-433-3277
F: 303-433-3278

Request an appointment »

Mon: 8:00 am – 5:30 pm
Tues: 8:00 am – 5:30 pm
Wed: 8:00 am – 5:30 pm
Thur: 8:00 am – 5:30 pm
Fri: 8:00 am – 4:30 pm
Sat & Sun: Closed

The office closes for lunch on:
Mon, Tues, Weds & Fri: 12:30pm- 1:30pm
Thurs: 12:00pm – 2:00 pm

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