Your Name
Email Address
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Does your child...
Skip or repeat words/lines when reading?
Always
Frequently
Occasionally
Never
Have trouble keeping attention on reading?
Always
Frequently
Occasionally
Never
Confuse similar-looking words or make silly mistakes in math?
Always
Frequently
Occasionally
Never
Demonstrate poor reading comprehension?
Always
Frequently
Occasionally
Never
Have difficulty copying from the board in class?
Always
Frequently
Occasionally
Never
Complain of headaches/eye strain during or after school?
Always
Frequently
Occasionally
Never
Report blurry vision, or double vision?
Always
Frequently
Occasionally
Never
Squint, close an eye, or blink excessively?
Always
Frequently
Occasionally
Never
Demonstrate an eye turn?
Always
Frequently
Occasionally
Never
Still reverse letters, numbers or words (after 1st grade)?
Always
Frequently
Occasionally
Never
Have poor handwriting or misalign numbers in math?
Always
Frequently
Occasionally
Never
Struggle with eye-hand coordination (for example, catching balls)?
Always
Frequently
Occasionally
Never
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