30 Question Predictive Checklist

Name

Phone Number

Age

After you consider each question, mark the column that applies
to the person you are assessing.

	Never	Seldom	Occasionally	Frequently	Always
Blur when looking at near.
Double vision, double or overlapping words on a page.
Headaches while or after doing near vision work.
Words appear to run together when reading.
Burning, itching or watery eyes.
Falls asleep when reading.
Seeing and visual work is worse at the end of the day.
Skips or repeats lines while reading.
Dizziness or nausea when doing near work.
Head tilts or one eye is closed or covered while reading.
Difficulty copying from the board.
Avoids doing near vision work such as reading.
Omits (drops out) small words while reading.
Writes up or down hill.
Misaligns digits or columns of numbers.
Reading comprehension low, or declines as day wears on.
Poor, inconsistent performance in sports.
Holds books too close, leans too close to computer screen.
Trouble keeping attention centered on reading.
Difficulty completing assignments on time.
First response is 'I can't' before trying.
Avoid sports and games.
Poor hand/eye coordination, such as poor handwriting.
Does not judge distances accurately.
Clumsy, accident prone, knocks things over.
Does not use or plan his/her time well.
Does not count or make change well.
Loses belongings and things.
Car or motion sickness.
Forgetful, poor memory.

Glasses and Contacts

(614) 410-5018

Quick Contact

Office Hours

Monday 9-4
Tuesday 8:30-4
Wednesday 8:30-4
Thursday 10-4
Friday closed
Saturday 8:30-12

Vision Therapy

Appointments for vision therapy are available during regular office hours. We also offer after school times, evenings, and Saturdays.

Our Doctors

Dr. Carole Burns, Dr. Kyla Cologgi, Dr. William Lay, Dr. Amy Lay, Dr. Kristyne Edwards, Dr. Nancy Evans, Dr. Greg Nixon, Dr. Stacy Stutler, Dr. Brad Johnson, Dr. Mark Wright (emeritus)