Part 1: Symptoms

Directions: Children - answer these questions together with your Parents. For every question, select the answer that best describes your situation.

If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question.

Never = Never
Occasionally = Less than 1 time / week
Frequently = At least 1 time / week
Always = Everyday

Do you have headaches or stomach aches or do you get nervous/anxious at school?* This field is required.

Always

Frequently

Occasionally

Never

While reading or watching video in a car, do you get a headache or stomach ache or feel unwell?* This field is required.

Always

Frequently

Occasionally

Never

Do you get sick to your stomach or nauseous on swings or circular rides?* This field is required.

Always

Frequently

Occasionally

Never

Do you have difficulty playing sports, or doing gymnastics or dance?* This field is required.

Always

Frequently

Occasionally

Never

Do you have trouble catching baseballs or footballs or Frisbees?* This field is required.

Always

Frequently

Occasionally

Never

When you are walking, do you bump into people or furniture or door frames?* This field is required.

Always

Frequently

Occasionally

Never

Are you anxious or nervous?* This field is required.

Always

Frequently

Occasionally

Never

Does it take you a long time to finish your homework?* This field is required.

Always

Frequently

Occasionally

Never

Do you have to read the same thing a couple of times to really understand it?* This field is required.

Always

Frequently

Occasionally

Never

When reading, do you skip lines or lose your place OR do you use a guide (finger, ruler or a piece of paper) to help you keep your place?* This field is required.

Always

Frequently

Occasionally

Never

When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?* This field is required.

Always

Frequently

Occasionally

Never

Do bright lights hurt your eyes?* This field is required.

Always

Frequently

Occasionally

Never

Do you close or cover one eye to make it easier to see?* This field is required.

Always

Frequently

Occasionally

Never

Do you ever see two of everything (double vision)?* This field is required.

Always

Frequently

Occasionally

Never

When reading or working on the computer or electronic device, do your eyes feel tired or does your vision get blurry?* This field is required.

Always

Frequently

Occasionally

Never

When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?* This field is required.

Always

Frequently

Occasionally

Never

Part 2: Level of Discomfort

On an average day, how much are you bothered by the 8 symptoms listed below?

(Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)

Dizziness10 is the worst it could be, and 0 means you have none of that symptom

Nausea10 is the worst it could be, and 0 means you have none of that symptom

Anxiety10 is the worst it could be, and 0 means you have none of that symptom

Headache10 is the worst it could be, and 0 means you have none of that symptom

Neckache10 is the worst it could be, and 0 means you have none of that symptom

Unsteady with Walking10 is the worst it could be, and 0 means you have none of that symptom

Sensitivity to Light10 is the worst it could be, and 0 means you have none of that symptom

Reading Difficulty10 is the worst it could be, and 0 means you have none of that symptom

Part 3: Previous Diagnosis

Have you ever been diagnosed with...

Learning Disability (LD)* This field is required.

YESNO

Dyslexia?* This field is required.

YESNO

Torticollis? * This field is required.

YESNO

Lazy eye?* This field is required.

YESNO

ADD / ADHD?* This field is required.

YESNO

Migraines or headache?* This field is required.

YESNO

Traumatic brain injury or concussion?* This field is required.Have you experienced or been diagnosed with either?

YESNO

Does your child blink their eyes a lot / much more than most children? * This field is required.

YESNO

Are your child’s verbal skills far ahead of their reading skills?* This field is required.

YESNO

Has your child ever had an eye operation?* This field is required.

YESNO

Comment SectionIf you want to tell us more about your symptoms, or if you have specific questions, record them here. We will combine this information with the responses you entered above to provide you with a more detailed interpretation of the results.

Name* This field is required.

First Name

Last Name

Age* This field is required.

Part 1: Symptoms

Directions: Children - answer these questions together with your Parents. For every question, select the answer that best describes your situation.

If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question.

Never = Never Occasionally = Less than 1 time / week Frequently = At least 1 time / week Always = Everyday

Part 2: Level of Discomfort

On an average day, how much are you bothered by the 8 symptoms listed below?

(Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)

Part 3: Previous Diagnosis

Have you ever been diagnosed with...

Never = Never
Occasionally = Less than 1 time / week
Frequently = At least 1 time / week
Always = Everyday