Vision Quiz Full Name* First Last City* Email* Phone*Any of the following symptoms may indicate a functional vision problem. Please read and check the symptoms that you are currently experiencing. This is a critical step in helping us understand the type and amount of functional vision problem that may exist. Do you (or your child if you are filling this out on their behalf) experience any of the following?Check all that apply: 1. Skip lines while reading or copying 2. Lose your place while reading or copying 3. Skip words while reading or copying 4. Substitute words while reading or copying 5. Reread words or lines 6. Reverse letters, numbers, or words 7. Use a finger or marker to keep place while reading or writing 8. Read very slowly 9. Experience poor reading comprehension 10. Experience difficulty remembering what you have read 11. Hold your head very close (within 7-8 inches) to your reading or writing materials 12. Squint, close, or cover one eye while reading 13. Tilt your head in an unusual posture when reading or writing 14. Experience headaches after intense visual activities such as reading or computer work 15. Notice that your eyes hurt or feel tired after close work 16. Feel unusually tired after completing a visual task 17. Experience double vision 18. Notice that vision blurs at a distance when looking up from near work 19. Experience crooked or poorly spaced writing 20. Notice that print seems to move or go in and out of focus when reading 21. Experience poor spelling skills 22. Find that letter or lines “run together” when reading 23. Find that words appear to jump on the page when reading 24. Misalign letters and numbers 25. Make errors when copying 26. Experience difficulty tracking moving objects such as balls, etc. 27. Experience unusual clumsiness or poor coordination 28. Experience difficulty with eye-hand coordination sports such as baseball, etc. 29. Experience an eye that turns in or out 30. See more clearly with one eye than the other with best glasses prescription 31. Feel sleepy while reading 32. Dislike tasks requiring sustained concentration 33. Confuse right and left directions 34. Become restless when working at a desk 35. Tend to lose awareness of surroundings when concentrating 36. Find you must “feel” things to see them 37. Suffer from carsickness or motion sickness 38. Experience unusual blinking 39. Experience unusual eye rubbing 40. Experience dry eyes 41. Experience watery eyes 42. Experience red eyes 43. Experience sensitivity to light Learn about the Chromagen system for for Visual Reading Disorders associated with Dyslexia.