SYMPTOM CHECKLIST | Vital Vision Therapy

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Symptom Checklist to Identify Vision Problems

First Name

Last Name

Phone

Physical symptoms associated with a vision problem:

Double vision

Blurry vision

Attention difficulties

Concentration issues

Headaches or eye strain

Nausea or dizziness

While reading or performing a near vision task:

Reading below grade level

Holds reading material or object too close

Closes or covers one eye

Tilts head toward book or object

Uses finger or ruler to read

Frequently loses place and/or skips words

Repeats lines when reading

Fatigues easily

Rubs eyes during or after periods of reading or close work

Reports that words move on page or run together

Often knocks things over on a desk or table

Avoids or dislikes homework

Common Behaviors associated with a vision problem:

One eye drifts or turns in a different direction than the other

Turns or tilts head while reading or during other visual activities

Head is frequently tilted to one side or one shoulder is noticeably higher

Squinting or closing of one eye

Excessive blinking or squinting

Poor visual/motor coordination skills (hand-eye coordination)

Problems judging distances while moving in space

Frequently bumps into objects or drops things

Frequently loses items

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Could a vision problem be impacting your academic success, athletic performance, or daily activities?

If you or a loved one shows any of these behaviors, schedule a comprehensive binocular vision evaluation with an experienced eye doctor.

Early detection of a vision problem will enable you to get the support you need through eyeglasses, contact lenses, or vision therapy – and will enhance your performance in school, at work, on the sports field, and in your day to day life!

Did you know that vision problems can affect up to 25 in every 100 children?

–

That’s at least six students in every class!

Schedule a consultation today!

visiontherapy@20twentymt.com

Phone: 406.404.1375

Fax: 406.577.2406

VISIT US:

270 W Kagy Blvd Suite B Bozeman, Montana 59715

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