Functional Vision Symptom Checklist If this is an emergency, do not contact us via email, please use our emergency contact information. Your two cents is worth a bundle to us... Help us help you better by letting us have your comments on our services.Your Name* First Last Email PhonePlease check all that apply. Skip lines when reading or copying Lose your place when reading or copying Skip words while reading or copying Substitute words when reading or copying Reread words or lines Reverse letters, numbers or word Confuse right and left directions Experience poor reading comprehension Experience poor reading comprehension Hold head very close (within 7-8 inches) to reading and/or writing material Squint, close or cover one eye when reading Tilt head in an unusual posture when reading or writing Use a finger or marker to keep place when reading or writing Read very slowly Experience headaches after intense visual activities (reading or computer work) Eyes hurt or feel tired after close work Feel unusually tired after completing a visual task Vision blurs at a distance when looking up from near work Poor spelling skills Experience crooked or poorly spaced writing Misalign letters and numbers Make errors when copying Tend to lose awareness of surroundings when concentrating Dislike tasks requiring sustained concentration Feel sleepy when reading Become restless when working at a desk Difficulty when tracking moving objects such as balls, etc. Must “feel” things to see them Unusual clumsiness or poor coordination Difficulty with eye-hand coordination sports such as baseball, etc. Suffer from carsickness or motion sickness Suffer from carsickness or motion sickness Experience unusual blinking Experience unusual eye rubbing Experience dry eyes Experience watery eyes Experience red eyes Experience sensitivity to light Eye turns in or out One eye sees more clearly than the other with best glasses prescription Experience double vision Words appear to jump on the page when reading Letters or lines “run together” when reading Notice that print seems to move or go in and out of focus when reading Email Please provide an email address so we can contact you.PhonePlease provide a telephone number, with area code, so we can contact you.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.