• Please 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
  • 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.
  • This field is for validation purposes and should be left unchanged.