| Question | Never | Seldom | Occasionally | Frequently | Always |
|---|
| Headaches with near work | | | | | |
| Words run together while reading | | | | | |
| Burning, itchy, or watery eyes | | | | | |
| Skipping/repeating lines while reading | | | | | |
| Tilting head or closing one eye when reading | | | | | |
| Difficulty copying from a chalkboard | | | | | |
| Avoiding near work or reading | | | | | |
| Omitting small words when reading | | | | | |
| Writing uphill or downhill | | | | | |
| Misaligning digits/columns of numbers | | | | | |
| Poor reading comprehension | | | | | |
| Holding books or near work very close to eyes | | | | | |
| Short attention span with near work | | | | | |
| Difficulty completing assignments on time | | | | | |
| Saying "I can't" before trying something | | | | | |
| Clumsiness and knocking things over | | | | | |
| Poor use of time | | | | | |
| Losing belongings or misplacing things | | | | | |
| Forgetting things | | | | | |
