Vision Therapy Online Assessment Many kinds of vision problems reveal themselves most easily in behavior, posture and attitude. These signs are usually associated most closely with long periods of visual work done at less than arm’s length from a child’s eyes. You can easily identify vision problems simply by observing your child and marking this checklist. If you mark more than a few signs, there is good reason to suspect a vision problem.Name* First Last Please enter your name.Child's Name* First Last Please enter your child's nameEmail* Phone*Child's Date of Birth* MM DD YYYY Please enter your child's date of birth.Please check the signs that best describe your child:Eyesight & eye teaming skills Does your child squint when looking up from reading? Have trouble seeing the chalkboard? Frequently blink or rub eyes? Has headaches after doing school work? Hold books extremely close? Report that things look blurry? Difficulty concentrating or staying on task when reading or writing? Avoids, or even fights doing homework? Visually directed reading skills Spend a long time doing homework that should take only a few minutes? Reduced attention span, can concentrate for only a moderate time? Reads very slowly? Skips or re-reads words and lines? Uses finger to follow while reading (beyond 2nd grade)? Dislikes reading and does not even read for pleasure? Frequently loses place when reading? Does better at math than English, history or social studies? Gets tired quickly when doing reading or homework? Vision Processing Short attention span? Can concentrate on reading work for only a few minutes? Daydreams a lot? Stares off into the distance frequently? Reverses words or letters (was for saw, b for d) beyond 2nd grade? Difficulty with comprehension or understanding? Poor memory or easily forgets? Extreme effort required to get work done? Learns best through auditory tactics (listens to learn)? Misbehavior has become a problem (to cover up poor school performance), such as: - acting up when asked to do school work - being moody or depressed about school and life? Is more than 1 year behind group in reading-related skills? Poor or very slow handwriting? Poor spelling skills? Has trouble copying? General Behavior:Is child active in sports?YesNoIs child awkward or accident prone?YesNoLike to touch things (learns through hands, not eyes)How does your child react to school stress? Tries harder Performance drops Avoids work Behavior changes related to school? Often angry Class clown Depressed Moody We recognize that there are many components that affect a child’s learning ability and behavior. However, the information in this personal history form is highly accurate in predicting the presence of vision and/or vision processing problems. A comprehensive vision screening- which targets visual processing and developmental skills, is essential in determining how much vision is affecting your child’s performance and behavior. We provide these screenings at no charge.