Quality of Life Survey

Danny the dragon
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

Personal Information

Child's Name(Required)
DD slash MM slash YYYY
Parent Name 1
Parent Name 2
Does your child live with both parents?