VT Questionnaire

Name: Ancaster Family Eyecare
Address: 1146 Wilson St W # 4, Ancaster, ON, L9G 3K9, CA
Telephone: 905-769-2020
Price range: $000 - $300

Name
First Last
Date
MM slash DD slash YYYY
Please assign a value between 0 and 4 for each symptom 0= never or non-existent 1= seldom 2= occasionally 3=frequently 4= always

Untitled Survey Field

	Never or non-existent	Seldom	Occasionally	Frequently	Aways
Blurred vision at near
Double vision
Headaches associated with near work
Burning, stinging, watery eyes
Falling asleep when reading
Vision worse at the end of the day
Skipping or repeating lines when reading
Dizziness or nausea associated with near work
Head tilt or closing one eye when reading
Difficulty copying from the chalkboard
Avoidance of reading and near work
Omitting small words when reading
Writing uphill or downhill
Misaligning digits in columns of numbers
Reading comprehension declining over time
lnconsistent/poor sports performance
Holding reading material too close
Short attention span
Difficulty completing assignments in reasonable time
Saying "I can't" before trying
Avoiding sports and games
Difficulty with hand tools - scissor, screwdriver, calculator, keys
Inability to estimate distances accurately
Tendency to knock things over on desk or table
Difficulty with time management
Difficulty with money concepts, making change
Misplaces or loses papers, objects, belongings
Car Sickness/motion sickness
Forgetful, poor memory