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Vision Problem Symptom Survey
All Ages Vision Care
Vision Problem Symptom Survey
Are you struggling to determine if you or your child has a vision problem? Are you trying to decide if you should go a step further beyond your basic eye exam? Our 20 question survey should take less than 5 minutes of your time. If you are interested in the survey for your young child, read the questions and answers to him/her trying not to prompt them to answer any particular way. At the end of the survey, we will total your points and email our recommended course of action to you.
CLICK THE "CONTINUE" BUTTON BELOW TO START THE SURVEY.
1) Do your eyes get tired when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
2) Do your eyes feel uncomfortable when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
3) Do you get headaches when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
4) Do you feel sleepy when you are reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
5) Do you lose concentration when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
6) Do you have trouble remembering what you read?
Never
Not Very Often
Sometimes
Fairly Often
Always
7) Do you have double vision when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
8) Do you see words move, jump, swim or appear to float on the page when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
9) Do you feel like you read slowly?
Never
Not Very Often
Sometimes
Fairly Often
Always
10) Do your eyes ever hurt when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
11) Do your eyes ever feel sore when reading or doing close work?
Never
Not Very often
Sometimes
Fairly Often
Always
12) Do you experience a "pulling" feeling around your eyes when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
13) Do you notice words blurring or coming in and out of focus when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
14) Do you lose your place when reading or doing close work?
Never
Not Very Often
Sometimes
Fairly Often
Always
15) Do you ever have to reread the same line of words when reading?
Never
Not Very Often
Sometimes
Fairly Often
Always
16) Do you have trouble with depth perception when driving?
Never
Not Very Often
Sometimes
Fairly Often
Always
17) Are you a poor speller or have trouble visualizing what is read?
Never
Not Very Often
Sometimes
Fairly Often
Always
18) Do you get dizzy or nauseated when reading or riding in a car?
Never
Not Very Often
Sometimes
Fairly Often
Always
19) Do you have poor handwriting or have problems getting ideas on paper?
Never
Not Very Often
Sometimes
Fairly Often
Always
20) Do you reverse letters or numbers or have trouble remembering left and right?
Never
Not Very Often
Sometimes
Fairly Often
Always
Please tell us any additional information about your vision problem(s) that might be helpful.
Congratulations! You have completed the survey.
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Phone Number
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