Vision and Learning Screener Name*AgeGradeTeacherSchoolPlease put an “X” in the column that best shows how often this happens to your child. How often does this happen? Never 0 A little 1 Sometimes 2 A lot 3 Always 4 1. Headaches with reading or writing012342. Words slide together or get blurry when reading012343. Reads below grade level012344. Loses place while reading012345. Head tilt or closes an eye when reading012346. Hard to copy from the board012347. Doesn’t like reading or writing012348. Leaves out small words when reading012349. Hard to write in a straight line0123410. Burning, itching, or watery eyes0123411. Hard to understand what he/she has read0123412. Holds book very close0123413. Hard to pay attention when reading0123414. Hard to finish assignments on time0123415. Gives up easily (says “I can’t” before trying)0123416. Bumps into things, knocks things over0123417. Homework takes too long0123418. Daydreams0123419. In trouble for being off task at school01234 Number of total marks in each column Multiply total marks in each column by: x0 x1 x2 x3 x4 Score for each column __ __ __ __ __ Total Score for all columns _______________**Total score greater than 16 indicates the child is at risk for a vision-based learning problem. Further evaluation by a DEVELOPMENTAL-pediatric optometrist is recommended.NameThis field is for validation purposes and should be left unchanged.