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Pre-Screen Yourself

You or your child could be at risk of a Binocular Vision Dysfunction.
Please answer these questions pertaining to you or your child accordingly.

Check the most appropriate answer.
N= Never, S= Sometimes, O= Often, A= Always

1. Blur When Looking at Near?
NSOA
2. Double Vision?
NSOA
3. Headaches with Near Work?
NSOA
4. Words Run Together When Reading?
NSOA
5. Burning, Itching, Watery Eyes?
NSOA
6. Falls Asleep When Reading?
NSOA
7. Sees Worse at the End of the Day?
NSOA
8. Skips/Repeats Lines When Reading?
NSOA
9. Dizzy/Nausea with Near Work?
NSOA
10. Head Tilt or Close One Eye When Reading?
NSOA
11. Difficulty Copying From the Chalkboard?
NSOA
12. Avoids Near Work / Reading?
NSOA
13. Omits Small Words When Reading?
NSOA
14. Writes Up or Down Hill?
NSOA
15. Misaligns Digits / Columns of Numbers?
NSOA
16. Reading Comprehension Poor?
NSOA
17. Poor / Inconsistent in Sports?
NSOA
18. Holds Reading Too Close?
NSOA
19. Trouble Keeping Attention on Reading?
NSOA
20. Difficulty Completing Assignments on Time?
NSOA
21. Says "I Can't" Before Even Trying?
NSOA
22. Avoids Participation in Sports / Games?
NSOA
23. Poor Hand / Eye ( Poor Handwriting)?
NSOA
24. Does Not Judge Distance Accordingly?
NSOA
25. Clumsy Knocks Over Things?
NSOA
26. Does Not Use Time Well?
NSOA
27. Does Not Make Change Well?
NSOA
28. Loses Belongings / Things?
NSOA
29. Car Motion or Sickness?
NSOA
30. Forgetful / Poor Memory?
NSOA

Score the Test:

Step 1:
For every “N” give that question a 0
For every “S” give that question a 1
For every “O” give that question a 2
For every “A” give that question a 3

Step 2:
Add all of the “S” numbers together.
Add all of the “O” numbers together.
Add all of the “A” numbers together.

Step 3:
Then Add the Three total numbers together to achieve your final score.

Results:
If your score is 15-25 then your Quality of Life is somewhat affected by your visual system.

If your Score is 25 or greater then your Quality Of Life is significantly affected by your visual system and an evaluation is strongly recommended.

Example:
5 S’s x 1= 5
10 O’s x 2 = 20
15 A’s x 3 = 45

Total = 70
Binocular Vision Exam is Strongly Indicated