Visual Efficiency Checklist

Any of the following symptoms may indicate a functional vision problem. Please mark the symptoms that occur and use the scoring criteria which will automatically calculate at the bottom of the page to determine if a functional vision evaluation is recommended. If you are using Internet Explorer 8, any checks you make will not be shown when you print the form unless you have "Compatability View" turned on. (This can be located under "Tools".) 

If you would like to schedule an evaluation, please make note of your score as you will need this when scheduling.

Check all that apply:


Score: 0
Criteria:
  • 15-20 points total = Possible functional vision problems
  • 21-30 points total = Probable functional vision problems
  • Over 30 points total = Definite functional vision problems
  • 15+ total points = Functional vision evaluation recommended