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30 Question Predictive Checklist
Name ______________________________________________________
Date_______________________________ Age____________________

After you consider each question, mark the column that applies to the person you are assessing.

  1. Blur when looking at near                                0 1 2 3 4 
  2. Double vision, doubled or overlapping words on page      0 1 2 3 4 
  3. Headaches while or after doing near vision work          0 1 2 3 4 
  4. Words appear to run together when reading                0 1 2 3 4 
  5. Burning, itching or watery eyes                          0 1 2 3 4 
  6. Falls asleep when reading                                0 1 2 3 4 
  7. Seeing and visual work is worse at the end of the day    0 1 2 3 4 
  8. Skips or repeats lines while reading                     0 1 2 3 4 
  9. Dizziness or nausea when doing near work                 0 1 2 3 4 
  10. Head tilts or one eye is closed or covered while reading 0 1 2 3 4 
  11. Difficulty copying from the chalkboard                   0 1 2 3 4 
  12. Avoids doing near vision work such as reading            0 1 2 3 4 
  13. Omits (drops out) small words while reading              0 1 2 3 4 
  14. Writes up or down hill                                   0 1 2 3 4 
  15. Misaligns digits or columns of numbers                   0 1 2 3 4 
  16. Reading comprehension low, or declines as day wears on   0 1 2 3 4 
  17. Poor, inconsistent performance in sports                 0 1 2 3 4 
  18. Holds books too close, leans too close to computer screen 0 1 2 3 4 
  19. Trouble keeping attention centered on reading            0 1 2 3 4 
  20. Difficulty completing assignments on time                0 1 2 3 4 
  21. First response is I cant before trying                0 1 2 3 4 
  22. Avoids sports and games                                  0 1 2 3 4 
  23. Poor hand/eye coordination, such as poor handwriting     0 1 2 3 4 
  24. Does not judge distances accurately                      0 1 2 3 4 
  25. Clumsy, accident prone, knocks things over               0 1 2 3 4 
  26. Does not use or plan his/her time well                   0 1 2 3 4 
  27. Does not count or make change well                       0 1 2 3 4 
  28. Loses belongings and things                              0 1 2 3 4 
  29. Car or motion sickness                                   0 1 2 3 4 
  30. Forgetful, poor memory                                   0 1 2 3 4 
20-24 points = suspect 25 points or more=refer for care
TOTAL SCORE

From Idealvt