Eye Brain Connection Minors Symptom Questionnaire

Please mark the column that most accurately describes your current vision with your glasses or contacts on:

Rows	Never	Seldom	Occasionally	Frequently	Always
I get a headache when I do near work
I use a finger or marker to keep my place when I read
I see double, or cover or close an eye while I read
Words move, wiggle, float or jump when I read
I get dizzy or nauseated when I do near work
I tilt my head when I read or when I am talking to people
I get close to the page when I read or write
I lose my place while reading
I am slow copying from the chalkboard
I skip words or lines while reading
I have trouble understanding what I read
I read small words backwards (was-saw)
I get tired or sleepy while reading
My eyes get tired, itchy, watery or burn when I read
Print in a book looks blurry
I guess at words

I can only read for __________
I read for pleasure:
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I understand and agree that all services and materials provided by Dr. Trinka shall be charged directly to me and that I am responsible for final payment of any such services and materials regardless of insurance coverage. I hereby authorize the release by Dr. Trinka of all information and records deemed necessary to secure payment or to benefit my health.
I have read, understood, and agree to the above. Parent/Guardian Signature:
Should be Empty: