QOL Form

Quality of Life Checklist

Check the column that best represents the occurrence of each symptom

  • 0 = Never

  • 1 = Seldom

  • 2 = Occasionally

  • 3 = Frequently

  • 4 = Always

Blurred close vision
Double vision
Headaches with near work
Words run together reading
Burning, itchy, watery eyes
Falls asleep reading
Sees worse at the end of day
Skips/repeats lines reading
Dizzy/nauseated by near work
Head tilt/one eye closed to read
Difficulty copying from chalkboard
Avoids near work/reading
Omits small words when reading
Writes uphill/downhill
Misaligns digits/columns of numbers
Poor reading comprehension
Poor/inconsistent in sports
Holds reading too close
Trouble keeping attention on reading
Difficulty completing work on time
Says "I can't" before trying
Avoids sports/games
Poor hand/eye coordination
Poor handwriting
Does not judge distance accurately
Clumsy, knocks things over
Poor time use/management
Does not make change well
Loses things/belongings
Car or motion sickness
Forgetfulness/poor memory

  • 15 = Routine eye exam recommended

  • 16-24 = Comprehensive exam with developmental OD recommended

  • 25 = Developmental vision problem likely, comprehensive exam with developmental OD strongly recommended