1. Do you have headaches or face pain? | | | | |
2. Do your eyes hurt and/or does it hurt to move your eyes? | | | | |
3. Do you have neck pain or a stiff neck or upper back pain? | | | | |
4. Do you have stomachaches or nausea? | | | | |
5. Do you get car sickness or motion sickness? | | | | |
6. Did you get sick in the car seat when you were a small child? | | | | |
7. Do you get sick to your stomach or nauseous on swings or circular rides? | | | | |
8. Does riding in the car give you headaches or stomach aches? | | | | |
9. Do you have trouble reading in the car? | | | | |
10. Do you feel clumsy or klutzy or uncoordinated? | | | | |
11. When you are walking, do you bump into people or furniture or door frames? | | | | |
12. Do you feel funny or dizzy when you bend over and stand back up quickly? | | | | |
13. Are you anxious or nervous? | | | | |
14. In grocery stores or malls, do you stay close (cling) to your Mom or Dad? (Do you feel uncomfortable in grocery stores or malls?) | | | | |
15. Do you tend to play alone or with just a few other kids? (Do you tend to play apart from the main group of kids?) | | | | |
16. Is reading hard for you or are you a slow reader? | | | | |
17. Do you have to read the same thing a couple of times to really understand it? | | | | |
18. Do you use your finger or a ruler or a piece of paper to help you keep your place when you are reading? | | | | |
19. Do you skip lines or lose your place when you are reading? | | | | |
20. When you read, does it look like the letters are moving OR does it seem like words are bumping into each other? | | | | |
21. Do bright lights hurt your eyes? | | | | |
22. Do you close or cover one eye to make it easier to see? | | | | |
23. Do you have trouble catching baseballs or footballs or Frisbees? | | | | |
24. Do you ever see two of everything (double vision)? | | | | |
25. Is it hard for you to watch 3-D movies? | | | | |
26. When reading or working on the computer, do your eyes feel tired or does your vision get blurry? | | | | |
27. When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry? | | | | |