Interactive Quality of Life Survey

Interactive Quality of Life Survey

Interactive Quality of Life Survey

Interactive Quality of Life Survey

Interactive Quality of Life Survey

Quality of Life Survey

This survey will help indicate how high your child's risk is for a vision-based learning problem.

Never A Little Sometimes A Lot Always
1. Headaches while reading or writing
2. Words slide together or get blurry when reading
3. Reads below grade level
4. Loses place while reading
5. Head tilt or closes an eye when reading
6. Hard to copy from the board
7. Doesn't like reading or writing
8. Leaves out small words when reading
9. Hard to write in a straight line
10. Burning, itching, or watery eyes
11. Hard to understand what he/she has read
12. Holds book very close
13. Hard to pay attention when reading
14. Hard to finish assignments on time
15. Gives up easily (says "I can't" before trying)
16. Bumps into things, knocks things over
17. Homework takes too long
18. Daydreams
19. In trouble for being off task at school

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