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 Having Vision Problems? Contact the experts at Heartland Eye Consultants. Call us at 402-493-6500
