30 Point Predictive Checklist Name(Required) First Last Date(Required) MM slash DD slash YYYY Age:(Required)After you consider each guestion, mark the column that applies to the person you are assessing.Blur when looking at near(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Double vision, doubled or overlapping words on page(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Headaches while or after doing nearvision work(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Words appear to run together when reading(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Burning, itching or watery eyes(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Falls asleep when reading(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Seeing and visual work is worse at the end of the day(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Skips or repeats lines while reading(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Dizziness or nausea when doing near work(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Head tilts or one eye is closed or covered while reading(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Difficulty copying from the chalkboard(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Avoids doing near vision work such as reading(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Omits (drops out) small words while reading(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Writes up or down hill(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Misaligns digits or columns of numbers(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Reading comprehension low, or declines as day wears on(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Poor, inconsistent performance in sports(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Holds books too close, leans too close to computer screen(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Trouble keeping attention centered on reading(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Difficulty completing assignments on time(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS First response is "l can't" before trying(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Avoids sports and games(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Poor hand/eye coordination, such as poor handwriting(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Does not judge distance accurately(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Clumsy, accident prone, knocks things over(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Does not use or plan his/her time well(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Does not count or make change well(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Loses belongings and things(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Car or motion sickness(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Forgetful, poor memory(Required) NEVER SELDOM OCCASIONALLY FREQUENTLY ALWAYS Your score is:your score is suspicious I would refer you for a treatment
