30 Question Predictive Checklist Name First Middle Last PhoneEmail AgeAfter you consider each question, mark the column that applies to the person you are assessing.Blur when looking at near.NeverSeldomOccasionallyFrequentlyAlwaysDouble vision, double or overlapping words on a page.NeverSeldomOccasionallyFrequentlyAlwaysHeadaches while or after doing near vision work.NeverSeldomOccasionallyFrequentlyAlwaysWords appear to run together when reading.NeverSeldomOccasionallyFrequentlyAlwaysBurning, itching or watery eyes.NeverSeldomOccasionallyFrequentlyAlwaysFalls asleep when reading.NeverSeldomOccasionallyFrequentlyAlwaysSeeing and visual work is worse at the end of the day.NeverSeldomOccasionallyFrequentlyAlwaysSkips or repeats lines while reading.NeverSeldomOccasionallyFrequentlyAlwaysDizziness or nausea when doing near work.NeverSeldomOccasionallyFrequentlyAlwaysHead tilts or one eye is closed or covered while reading.NeverSeldomOccasionallyFrequentlyAlwaysDifficulty copying from the board.NeverSeldomOccasionallyFrequentlyAlwaysAvoids doing near vision work such as reading.NeverSeldomOccasionallyFrequentlyAlwaysOmits (drops out) small words while reading.NeverSeldomOccasionallyFrequentlyAlwaysWrites up or down hill.NeverSeldomOccasionallyFrequentlyAlwaysMisaligns digits or columns of numbers.NeverSeldomOccasionallyFrequentlyAlwaysReading comprehension low, or declines as day wears on.NeverSeldomOccasionallyFrequentlyAlwaysPoor, inconsistent performance in sports.NeverSeldomOccasionallyFrequentlyAlwaysHolds books too close, leans too close to computer screen.NeverSeldomOccasionallyFrequentlyAlwaysTrouble keeping attention centered on reading.NeverSeldomOccasionallyFrequentlyAlwaysDifficulty completing assignments on time.NeverSeldomOccasionallyFrequentlyAlwaysFirst response is 'I can't' before trying.NeverSeldomOccasionallyFrequentlyAlwaysAvoid sports and games.NeverSeldomOccasionallyFrequentlyAlwaysPoor hand/eye coordination, such as poor handwriting.NeverSeldomOccasionallyFrequentlyAlwaysDoes not judge distances accurately.NeverSeldomOccasionallyFrequentlyAlwaysClumsy, accident prone, knocks things over.NeverSeldomOccasionallyFrequentlyAlwaysDoes not use or plan his/her time well.NeverSeldomOccasionallyFrequentlyAlwaysDoes not count or make change well.NeverSeldomOccasionallyFrequentlyAlwaysLoses belongings and things.NeverSeldomOccasionallyFrequentlyAlwaysCar or motion sickness.NeverSeldomOccasionallyFrequentlyAlwaysForgetful, poor memory.NeverSeldomOccasionallyFrequentlyAlways