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Vision Quiz

COVD Quality of Life Checklist
To take the vision quiz, select the answer which best represents the occurrence of each symptom.
1. Blurry when looking at near?
- Never
- Seldom
- Occasionally
- Frequently
- Always
2. Headaches with near work?
- Never
- Seldom
- Occasionally
- Frequently
- Always
3. Do you see worse at the end of the day?
- Never
- Seldom
- Occasionally
- Frequently
- Always
4. Difficulty copying from the chalkboard?
- Never
- Seldom
- Occasionally
- Frequently
- Always
5. Avoid near work/reading?
- Never
- Seldom
- Occasionally
- Frequently
- Always
6. Hold your head too close to the page?
- Never
- Seldom
- Occasionally
- Frequently
- Always
7. Do you have double vision?
- Never
- Seldom
- Occasionally
- Frequently
- Always
8. Words run together while reading?
- Never
- Seldom
- Occasionally
- Frequently
- Always
9. Eyes burn, itch or seem watery?
- Never
- Seldom
- Occasionally
- Frequently
- Always
10. Do you fall asleep while reading?
- Never
- Seldom
- Occasionally
- Frequently
- Always
11. Do you close one eye or tilt your head while reading?
- Never
- Seldom
- Occasionally
- Frequently
- Always
12. Dizzy or nauseous with near work?
- Never
- Seldom
- Occasionally
- Frequently
- Always
13. Do you write up or down hill?
- Never
- Seldom
- Occasionally
- Frequently
- Always
14. Poor/inconsistent in sports?
- Never
- Seldom
- Occasionally
- Frequently
- Always
15. Do you avoid sports/games?
- Never
- Seldom
- Occasionally
- Frequently
- Always
16. Poor hand-eye coordination/poor handwriting?
- Never
- Seldom
- Occasionally
- Frequently
- Always
17. Clumsy/knock things over?
- Never
- Seldom
- Occasionally
- Frequently
- Always
18. Do you experience car/motion sickness?
- Never
- Seldom
- Occasionally
- Frequently
- Always
19. Skip or repeat lines when reading?
- Never
- Seldom
- Occasionally
- Frequently
- Always
20. Misalign digits/columns of numbers?
- Never
- Seldom
- Occasionally
- Frequently
- Always
21. Reading comprehension is poor?
- Never
- Seldom
- Occasionally
- Frequently
- Always
22. Trouble keeping attention while reading?
- Never
- Seldom
- Occasionally
- Frequently
- Always
23. Do you say, "I can't" before trying?
- Never
- Seldom
- Occasionally
- Frequently
- Always
24. Don't use your time well?
- Never
- Seldom
- Occasionally
- Frequently
- Always
25. Don't make change well with money?
- Never
- Seldom
- Occasionally
- Frequently
- Always
26. Do you lose belongings/things?
- Never
- Seldom
- Occasionally
- Frequently
- Always
27. Forgetful or poor memory?
- Never
- Seldom
- Occasionally
- Frequently
- Always
28. Do you have difficulty completing assignments on time?
- Never
- Seldom
- Occasionally
- Frequently
- Always
29. Does not judge distance accurately?
- Never
- Seldom
- Occasionally
- Frequently
- Always

Conveniently located in Omaha, Heartland Eye Consultants is a regional, specialty eye and vision care center serving all of Eastern Nebraska and Western Iowa, including but not limited to Council Bluffs, Lincoln, Sioux City, IA, South Sioux City, NE, Norfolk, NE and surrounding towns. Call us at (402) 493-6500

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9900 Nicholas Street Omaha, NE 68114

9900 Nicholas Street
Suite 250
Omaha, NE 68114

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Mon	8:15am - 5:15pm
Tue	9:00am - 5:15pm
Wed	8:15am - 5:15pm
Thu	8:15am - 5:15pm
Fri	8:15am - 5:15pm

© 2020 Heartland Eye Consultants

9900 Nicholas Street, Suite 250
Omaha, NE 68114

Phone: (402)493-6500
Fax: (402)493-4370