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GROSS MOTOR / VESTIBULAR NOTES

Symptom Survey

DrB010 mins

 

Parent Symptom Survey

Symptom Survey

Symptom Survey (CISS)

(for Patients ≥8 Years of Age)

Name _______________________________________ Date ______________________

Please answer the following questions about how your eyes feel when reading or

doing close work. (For patients ≤12 years of age, the intern/doctor should read the

question to the patient.)

Symptom: Never Infrequently – Sometimes Often – Fairly Always

1. Do your eyes feel tired when reading

or doing close work?

2. Do your eyes feel uncomfortable

when reading or doing close work?

3. Do you have headaches when

reading or doing close work?

4. Do you feel sleepy when reading or

doing close work?

5. Do you lose concentration when

reading or doing close work?

6. Do you have trouble remembering

what you have read?

7. Do you have double vision when

reading or doing close work?

8. Do you see the words move, jump,

swim, or appear to float on the page

when reading or doing close work?

9. Do you feel that you read slowly?

10. Do your eyes ever hurt when reading

or doing close work?

11. Do your eyes ever feel sore when

reading or doing close work?

12. Do you have a “pulling” feeling

around your eyes when reading or

doing close work?

13. Do words blur or come in and out

of focus when reading or doing close

work?

14. Do you lose your place while reading

or doing close work?

15. Do you have to reread the same line

of words when reading?

Score 0 for Never; 1 for Infrequently; 2 for Sometimes; 3 for Fairly Often; and 4 for Always.

TOTAL SCORE: __________

This Survey was developed by the Convergence Insufficiency Research Group.

 

 

Teacher Symptom Survey

Teacher Questionnaire

Teacher Questionnaire

 

To the teacher of ___________________Grade_______School__________________

 

The child named above is receiving vision care at our center. In order to address the

 

impact of vision problems on classroom performance, we would like your observations of this child’s behavior in school. It has been shown that the teacher is frequently the best observer for identifying vision problems that tend to interfere with

 

school work. The following checklist identifies many of the observable clues and

 

symptoms that are observed in a child with a vision problem. Please read through this

 

list and check items that you have noted to occur in this child’s case, along with the

 

frequency.

 

Symptom: Never – Infrequently – Sometimes – Fairly Always

 

1. Does the child report that his/her

 

eyes feel tired when reading or

 

doing close work?

 

2. Does the child report that his/her

 

eyes feel uncomfortable when

 

reading or doing close work?

 

3. Does the child report headaches

 

when reading or doing close work?

 

4. Does the child report that he/she

 

feels sleepy when reading or doing

 

close work?

 

5. Does the child report that he/she

 

loses concentration when reading or

 

doing close work?

 

6. Does the child have trouble

 

remembering what he/she has read?

 

7. Does the child report double vision

 

when reading or doing close work?

 

8. Does the child report that he/she

 

sees the words move, jump, swim, or

 

appear to float on the page when

 

reading or doing close work?

 

9. Does the child read slowly?

 

10. Does the child report that his/her

 

eyes ever hurt when reading or doing

 

close work?

 

11. Does the child report that his/her

 

eyes ever feel sore when reading or

 

doing close work?

 

12. Does the child report a “pulling”

 

feeling around his/her eyes when

 

reading or doing close work?

 

13. Does the child report that words blur

 

or come in and out of focus when

 

reading or doing close work?

 

14. Does the child lose his/her place

 

while reading or doing close work?

 

15. Does the child have to reread the

 

same line of words when reading?

 

16. Does the child make reversal errors

 

when reading (was for saw, on for

 

no) or writing (b for d)?

 

17. Does the child transpose letters or

 

numbers (21 for 12)?

 

18. Does the child have difficulty copying

 

written material?

 

19. Does the child have poor printing or

 

handwriting?

 

20. Does the child avoid reading?

 

21. Does the child have difficulty finishing

 

school assignments in a timely

 

manner?Please comment on the following:

 

1. Does this child have any academic problems? ___Yes ___No

 

If so, please explain (e.g., subject material, behavior, etc.) _______________________

 

________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

2. Is (s)he in the top third, middle third, or lower third of his/her class? __________

 

3. How does academic achievement compare with potential? ____________________

 

________________________________________________________________________

 

________________________________________________________________________

 

4. At what grade level does this child read? ___________________________________

 

5. Please check any areas of difficulty:

 

__ Vocabulary __ Word Recognition __ OralReading

 

__ Reading Rate __ Interpretation __ SilentReading

 

__ Attention __ Comprehension __ Memory

 

__ Math Skills __ Spelling __ Written Work

 

6. Do you feel that there are any factors that may be interfering with academic

 

achievement?____________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

22. Does the child misalign digits or

 

columns when doing math

 

assignments?

 

23. Does the child seem to be clumsy or

 

knock things over?

 

24. Does the child overlook small details

 

(reads beak for break) or misread

 

math symbols (– for +)?

 

25. Does the child have a short attention

 

span or is he/she easily distractible

 

when reading or studying?7. Any other observations and/or comments which you feel may be beneficial to us

 

would be appreciated. ___________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

May we contact you if further information is required? If so, please provide a telephone number at which you can be reached.

 

Teacher _____________________________________ Phone _____________________

 

School Name ____________________________________________________________

 

Address ________________________________________________________________

 

City______________________________________State__________ Zip __________

 

Signature _________________________________________ Date _________________

 

I hereby give my consent to release the above information

 

Parent or Guardian Signature ____________________________ Date _____________

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