Vision Screening Questionnaire

For Parents, Coach and Teacher

Does Your Child Have a Vision Problem That Might Be Interfering With School Performance?

If your child is not working up to potential in school there is a strong possibility that a vision problem might be present. According to experts, almost 50% of children with learning difficulties have vision disorders. In most cases these problems can be successfully treated leading to improved learning and better grades.

You can determine whether your child might have a learning related vision problem by completing the following questionnaire.

Print Out the form below and then for each question, CIRCLE the appropriate answer.

1. My child has difficulty concentrating and paying attention.
	1. never	2. sometimes	3. often
2. My child requires a lot of time to complete homework.
	1. never	2. sometimes	3. often
3. My child complains of blurred vision, or double vision when reading.
	1. never	2. sometimes	3. often
4. My child complains of eyestrain or headaches when reading.
	1. never	2. sometimes	3. often
5. My child loses his/her place when reading or skips words or lines.
	1. never	2. sometimes	3. often
6. My child has difficulty copying from the board.
	1. never	2. sometimes	3. often
7. My child has difficulty with handwriting.
	1. never	2. sometimes	3. often
8. My child reverses letters, numbers or confuses similar words.
	1. never	2. sometimes	3. often
9. My child becomes tired or sleepy after short periods of time or his/her reading comprehension deteriorates with time.
	1. never	2. sometimes	3. often
10. My child has struggled in school.
	1. never	2. sometimes	3. often

For each question your child's score will be 1, 2, or 3.

Add up the total score for the ten questions and compare it to the guidelines below.

Score	What That Score Means
10-12	Your child probably does not have a vision problem interfering with school performance.
13-18	Your child may have a vision problem interfering with school performance.
19-30	Your child almost certainly has a vision problem interfering with school performance.

If a child has a score greater than 12 it is strongly suggested that an evaluation be done testing those aspects of vision that might be contributing to learning difficulties. If a problem is detected, a Vision Therapy program may be recommended to eliminate the vision disorders.

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