PATIENT INFORMATION FORM
This form will give us important information that will help your optometrist to assess your vision.
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Learning Vision Symptoms Checklist
• Needs to touch things to understand them
• Doesn’t recognise the same word when rewritten
• Understands spoken word, but trouble with writing or reading
• Poor comprehension and attention span
• Complains of words moving, or colours/spots on page
• Car or motion sickness
• Omits small/short length words
• Slow to complete work
• Clumsy
• Word guessing
• Reversing letters/numbers
• Rubbing eyes and blinking often
• Fidgeting and can't sit still
• Continued disruptive behaviour
• Trouble copying from board
• Complains of blurring
• Poor posture when doing near work
• Writing uphill or downhill and Irregular letter or word spacing
• Rereads lines/loses place
• Headaches after reading or near work
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