AG logo as watermark in center - Alex Gage Family Optometrist
Appearance of Eyes
One eye appears to turn in or out at times
Reddened eyes or lids
Eyes tear excessively
Complaints when using eyes at desk
Headaches
Burning or itchy eyes after reading or deskwork
Print blurs after reading for a while
Complains of seeing double
Word’s ‘swim’ or move on the page
Behavioural Signs of Visual Problems
Eye Movements
Moves head a lot when reading.
Loses place frequently when reading.
Needs to use finger or marker to keep place.
Rereads or skips lines.
Short attention span when reading.
Omits words.
Eye Teaming
Repeats letters within words.
Omits letters, numbers or phrases.
Misaligns digits in columns.
Squints, closes or covers one eye.
Tilts head a lot when working at desk.
Odd working posture at desk activities.
Eye / Hand Co-ordination
Has to feel things ‘to get an idea’.
Writes crookedly, poor spaced; cannot stay on ruled lines.
Misaligns both horizontal and vertical lines of numbers.
Discomfort in hand when writing.
Repeatedly confuses left – right directions.
Has difficulties with ball activies.
Visual Visual Form Perception
Fails to recognise same word in next sentence.
Reverses letters/words in writing and copying.
Repeatedly confuses words with similar beginnings and endings.
Whispers to self for reinforcement while reading silently.
Uses ‘drawing with fingers’ to discriminate similarities and differences.
Spelling errors tend to be phonetic.
Can learn spelling for test, but forgets soon afterwards.
Refractive Status (near and far sightedness)
Quickly loses interest in reading
Blinks excessively at desk tasks or reading
Holds book too close, or gets close to deskwork
Makes errors copying from the board to paper or from page to page
Screws eyes up to see board, or asks to move closer.
Rubs eyes after short periods of visual activity.
Blinks to clear board after reading or writing
Auditory Difficulties
Often asks you to repeat things
Daydreams a lot in class
Easily distracted by background noises
Can not work in silent conditions
Unclear speech
Thankyou for your time!
PLEASE RETURN THIS FORM
DIRECTLY TO US AT:
48 Sandygate Road, Crosspool, Sheffield S10 5RY crosspool@alexgagevision.co.uk
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Parent Questionnaire
We will shortly be carrying out a visual assessment on the above named child, whom you teach. It would be most helpful if you could complete this questionnaire, based on anything you have observed in class.
It would also be most helpful if you could add any further information on the back of this sheet. All information will be treated in confidence.
You may obtain more information about our work at babo.co.uk
Child’s Name: Year Group:
School Teacher’s Name:
PLEASE TICK ALL SYMPTOMS SEEN
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