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Located at the corner of Omaha and Mt. Rushmore Rd.

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Home » Contact Us » Online Forms » 30 Signs Checklist

30 Signs Checklist

MM slash DD slash YYYY
Name(Required)
MM slash DD slash YYYY
Blur when looking at near
Double vision, doubled or overlapping words on page
Headaches while or after doing near vision work
Words appear to run together when reading
Burning, itching or watery eyes
Falls asleep when reading
Seeing and visual work is worse at the end of the day
Skips or repeats lines while reading
Dizziness or nausea when doing near work
Head tilts or one eye is closed or covered while reading
Difficulty copying from the chalkboard
Avoids doing near vision work such as reading
Omits (drops out) small words while reading
Writes up or down hill
Misaligns digits or columns of numbers
Reading comprehension low, or declines as day wears on
Poor, inconsistent performance in sports
Holds books too close, leans too close to computer screen
Trouble keeping attention centered on reading
Difficulty completing assignments on time
First response is “I can’t” before trying
Avoids sports and games
Poor hand/eye coordination, such as poor handwriting
Does not judge distances accurately
Clumsy, accident prone, knocks things over
Does not use or plan his/her time well
Does not count or make change well
Loses belongings and things
Car or motion sickness
Forgetful, poor memory
20-24 points = suspect
25 points or more = refer for care