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Home » Contact Us » 19 Item COVD-QOL Checklists

19 Item COVD-QOL Checklists

Name
MM slash DD slash YYYY

Check the column which best represents the occurrence of each symptom

A = Accommodation, B = Binocularity, 0 = Orientation, OM = Oculannotor, P = Perception, * = All

1. Headaches with near work - A
2. Words run together reading - B
3. Burn, itch, watery eyes
4. Skips/repeats lines reading - OM
5. Head tilt/close one eye when reading - B
6. Difficulty copying from chalkboard - A
7. Avoids near work/reading - A
8. Omits small words when reading - OM
9. Writes up/down hill - 0
10. Misaligns digits/columns of numbers - OM
11. Reading comprehension down
12. Holds reading too close - A
13. Trouble keeping attention on reading - P
14. Difficulty completing assignments on time*
15. Always says *I can't* before trying - P
16. Clumsy, knocks things over - 0
17. Does not use his/her time well
18. Loses belongings/things
19. Forgetful/poor memory

Tally up the column totals with the multipliers; any score of 20 or above is questionable of a visual deficit; A score of 25 or more is almost certainly a vision problem.

Click following button to see your result.