Vision Questionnaire Please follow the instructions below The quality of your vision can directly impact the quality of your life. By taking this quiz it will help us determine the best course of action for improving your vision and quality of life. Please click on the Next button to get started! These first seven questions test your knowledge of how vision works and what you know about vision therapy.If I have 20/20 vision, I can't have a vision problem.TrueFalseVision is learned.TrueFalseAll children are ready to read at the age of six.TrueFalseEyesight is hereditary. You can't do anything about it.TrueFalseVisual problems can affect a person's self-esteem and hinder success.TrueFalseSurgery is the only way to correct strabismus (a turned eye).TrueFalseAmblyopia (lazy eye) cannot be corrected after the person reaches the age of seven.TrueFalseThe following questions will help determine quality of life based someone's vision issues. Please select the option that best describes how often each symptom occursHeadaches from near workNeverSeldomOccasionallyFrequentlyAlwaysWords run together when readingNeverSeldomOccasionallyFrequentlyAlwaysBurning, itchy, watery eyesNeverSeldomOccasionallyFrequentlyAlwaysSkips/repeats lines when readingNeverSeldomOccasionallyFrequentlyAlwaysHead tilt/closes one eye when readingNeverSeldomOccasionallyFrequentlyAlwaysDifficulty copying from chalkboard/overheadNeverSeldomOccasionallyFrequentlyAlwaysAvoids near work/readingNeverSeldomOccasionallyFrequentlyAlwaysOmits small words when readingNeverSeldomOccasionallyFrequentlyAlwaysWrites uphill or downhillNeverSeldomOccasionallyFrequentlyAlwaysMisaligns digits/columns of numbersNeverSeldomOccasionallyFrequentlyAlwaysReading comprehension downNeverSeldomOccasionallyFrequentlyAlwaysHolds reading material too closeNeverSeldomOccasionallyFrequentlyAlwaysTrouble keeping attention on readingNeverSeldomOccasionallyFrequentlyAlwaysDifficulty completing assignments on timeNeverSeldomOccasionallyFrequentlyAlwaysAlways says "I can't" before tryingNeverSeldomOccasionallyFrequentlyAlwaysClumsy, knocks things overNeverSeldomOccasionallyFrequentlyAlwaysDoes not use his/her time wellNeverSeldomOccasionallyFrequentlyAlwaysLoses belongings/thingsNeverSeldomOccasionallyFrequentlyAlwaysForgetful/poor memoryNeverSeldomOccasionallyFrequentlyAlwaysWhat is your biggest concern regarding your vision?If you have any additional information or questions, please enter it in the box below. Be sure to click the Submit Questionnaire button to receive your results! Name E-mail Phone Number US State (or Country if outside USA) Time is Up!
