Symptom Checklist

Symptom Checklist in Chattanooga

Please fill out the following checklist to reflect your child or student’s experiences which will provide our behavioural optometrist with a better understanding of your possible concerns pertaining to your child or student’s visual abilities. Rate the following symptoms or scenarios on a scale of 0-4 as it most suitably applies to the patient.

0 = never

1 = rarely

2 = sometimes

3 = frequently

4 = always

 

The child or caretaker can fill out the questionnaire. If possible, it is recommended for the child to participate, however having a parent or teacher answer the following questions is also a great option.


never (0)rarely (1)sometimes (2)frequently (3)always (4)
Do you have a hard time gauging distance accurately?
Do you avoid reading or work that requires material to be up close?
Do you get headaches from work that is close up?
Do you experience motion sickness?
Do you not enjoy sports or find that you have inconsistent performance when participating in sports?
Do you notice that you have to sit close to the computer to see?
never (0)rarely (1)sometimes (2)frequently (3)always (4)
Do you skip or repeat lines?
Do you see double or blurry?
Do you feel exhausted?
Do you tilt your head or close an eye?
Do you skip small print when reading?
Do you have difficulty with reading comprehension?
Do you read very close up?
Do you find that it is hard to pay attention when reading?
Do you notice that you need to use your finger or something else to keep your place?
Is it easier if you close one eye?
Do you have better reading comprehension when someone else reads to you?
never (0)rarely (1)sometimes (2)frequently (3)always (4)
Do you find yourself re-reading in order to understand it?
Is it hard to remember what you read?
never (0)rarely (1)sometimes (2)frequently (3)always (4)
Do you confuse or reverse numbers/ letters?
Do you write on an upward or downward slant?
Do you have a hard time writing down answers and you find it easier to answer orally?
never (0)rarely (1)sometimes (2)frequently (3)always (4)
Do you struggle with time management?
Do you say “I can’t do it” before attempting to do so?
Do you bump into things and knock them over?
Do you tend to lose things?
Do you get frustrated often?
Do one or both of your eyes tend to wander in/ out/ up/ down?
never (0)rarely (1)sometimes (2)frequently (3)always (4)
Do you have a hard time with homework overall?
Is it challenging turning in projects on time?
Do you find it difficult to remember things?
Do you have a hard time looking down at your desk to copy notes from a board?
Do you misnumber rows or columns of numbers?
Do you have a hard time in math class?
Do you benefit from extra help?

20-24 points = suspect for binocular vision problem 

> 25 points or more = refer for developmental eye exam

 

If a child has multiple symptoms or any symptom that occurs always, the child should be assessed by our developmental optometrist. If you are unsure whether the symptoms require a developmental eye exam, please complete this form and our Certified Optometric Vision Therapist will assess the results and contact you with a recommendation of the next steps to take. 

Dr. McBryar cartoon

Dr. Heather McBryar

Dr. McBryar runs a specialty optometry practice, Amplify EyeCare Chattanooga, located in Hixson, Tennessee. Dr. McBryar specializes in the fields of developmental optometry, working with children and special needs to realize their full potential. 

She has many achievements in her field:

  • Diplomate of the American Board of Optometry (ABO)
  • Fellow of the College of Optometrists in Vision Development (COVD)
  • Candidate for Fellowship in the Neuro-Optometric Rehabilitation Association (NORA)

Book an Appointment

Related Articles

Contact Us To Amplify Your EyeCare

Amplify EyeCare Chattanooga Logo

Working Hours

Monday - Tuesday
7:30AM - 5:15PM

Wednesday - Thursday
8:00AM - 5:15PM

Friday - Sunday
Closed

Location
1043 Executive Drive Suite #101 Hixson, TN 37343
Fax
(423) 710 3966
Website Accessibility Policy
Safety protocols page
privacy policy
phone-handsetcalendar-fullarrow-up linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram