Questionnaire

Are there any academic/school-related concerns?

I have sustained:*

Headaches with near work*

Words run together while reading*

Burning, itchy or watery eyes*

Skipping/repeating lines while reading*

Tilting head or closing one eye when reading*

Avoiding near work or reading*

Omitting small words when reading*

Writing uphill or downhill*

Misaligning digits/columns of numbers*

Poor reading comprehension*

Holding books or near work very close to eyes*

Short attention span with near work*

Difficulty completing assignments on time*

Clumsiness and knocking things over*

Poor use of time*

Losing belongings or misplacing things*

Forgetting things*

Issues with prolonged screen time*