Lutz(813) 345-8544 Oldsmar(813) 915-0755
info@walesby3d.com
Walesby Vision Center — Where Vision Is More Than Just 20/20
A Walesby doctor running a fixation test with a patient at the exam lane
Are You At Risk?

Pre-Screen Yourself

You or your child could be at risk of a Binocular Vision Dysfunction. Please answer these questions pertaining to you or your child accordingly.

Check the most appropriate answer. N= Never, S= Sometimes, O= Often, A= Always

  1. Blur When Looking at Near?
  2. Double Vision?
  3. Headaches with Near Work?
  4. Words Run Together When Reading?
  5. Burning, Itching, Watery Eyes?
  6. Falls Asleep When Reading?
  7. Sees Worse at the End of the Day?
  8. Skips/Repeats Lines When Reading?
  9. Dizzy/Nausea with Near Work?
  10. Head Tilt or Close One Eye When Reading?
  11. Difficulty Copying From the Chalkboard?
  12. Avoids Near Work / Reading?
  13. Omits Small Words When Reading?
  14. Writes Up or Down Hill?
  15. Misaligns Digits / Columns of Numbers?
  16. Reading Comprehension Poor?
  17. Poor / Inconsistent in Sports?
  18. Holds Reading Too Close?
  19. Trouble Keeping Attention on Reading?
  20. Difficulty Completing Assignments on Time?
  21. Says “I Can’t” Before Even Trying?
  22. Avoids Participation in Sports / Games?
  23. Poor Hand / Eye (Poor Handwriting)?
  24. Does Not Judge Distance Accordingly?
  25. Clumsy Knocks Over Things?
  26. Does Not Use Time Well?
  27. Does Not Make Change Well?
  28. Loses Belongings / Things?
  29. Car Motion or Sickness?
  30. Forgetful / Poor Memory?
Download the Quality of Life Form (PDF)

Or call · Lutz (813) 345-8544 · Oldsmar (813) 915-0755