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Dr. Clayton Y. Gushiken

Dr. Gushiken is an optometrist who specializes in Vision Therapy.

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Visual Symptoms Checklist

HOW CAN I TELL IF MY CHILD OR STUDENT HAS A POSSIBLE VISION PROBLEM?

The best way to answer this is to fill out the checklist below.

If you answer “yes” to more than 3 questions, there is a strong probability that a vision problem is present. A developmental optometrist such as Dr. Gushiken can help alleviate these symptoms. Let the optometrist know what symptoms your child/student is experiencing. You can download and complete this checklist to bring with you to the appointment.

2.2-Visual-Symptoms-Checklist (Fillable PDF)Download

Student's Name *

First

Last

Age *

Grade Level *

Today's Date

Teacher's/Parent's Name *

Please ask the student the following questions:

1. Do your eyes feel tired when reading or doing close work?

Yes
No

2. Do your eyes feel uncomfortable when reading or doing close work?

Yes
No

3. Do you have headaches when reading or doing close work?

Yes
No

4. Do you feel sleepy when reading or doing close work?

Yes
No

5. Do you lose concentration when reading or doing close work?

Yes
No

6. Do you have trouble remembering what you read?

Yes
No

7. Do you have double vision when reading or doing close work?

Yes
No

8. Do you see the words move, jump, swim, or appear to float on the pagewhen reading or doing close work?

Yes
No

9. Are you a slow reader?

Yes
No

10. Do your eyes hurt when reading or doing close work?

Yes
No

11. Do your eyes feel sore when reading or doing close work?

Yes
No

12. Do your eyes feel like they’re pulling when reading/doing close work?

Yes
No

13. Do the words blur or come in and out of focus when reading?

Yes
No

List any other complaints your student makes concerning his/her vision:

Have you or anyone else ever noticed the following when observing this student:

1. Eyes frequently reddened

Yes
No

2. Frequent eye rubbing

Yes
No

3. Frequent sty-eye (pimple on eyelid)

Yes
No

4. Frowning

Yes
No

5. Excessive blinking

Yes
No

6. Bothered by light

Yes
No

7. Closes or covers an eye

Yes
No

8. Difficulty seeing distant objects

Yes
No

9. Head close to paper when reading or writing

Yes
No

10. Avoids/dislikes reading or other near tasks

Yes
No

11. Tilts head when reading or writing

Yes
No

12. Student says that he/she “hates reading”

Yes
No

13. Moves head when reading

Yes
No

14. Confuses letters and words

Yes
No

15. Reverses letters and words when reading

Yes
No

16. Reverses letters and words when writing

Yes
No

17. Confuses right or left

Yes
No

18. Skips, omits words

Yes
No

19. Loses place when reading

Yes
No

20. Uses finger as marker

Yes
No

21. Poor reading comprehension

Yes
No

22. Reading comprehension starts off well, but deteriorates over time

Yes
No

23. Writes or prints poorly

Yes
No

24. Difficult copying from the board

Yes
No

25. Tires easily

Yes
No

26. Difficulty with short term memory

Yes
No

27. Difficulty with long term memory

Yes
No

28. Short attention span/loses interest

Yes
No

29. Inconsistent academic performance

Yes
No

30. Poor/awkward large motor coordination

Yes
No

31. Poor/awkward fine motor coordination

Yes
No

32. Dislikes/avoids sports

Yes
No

33. Difficulty hitting/catching a ball

Yes
No

34. Inconsistent athletic performance (if student-athlete)

Yes
No

Please ask the student:

1. Do you feel that you have a problem with your reading?

Yes
No

2. If eyeglasses will help you read better, are you willing to wear glasses?

Yes
No

– Quick Links –

^{About Our Office | Dr. Gushiken
Patient Forms
Contact Info
Blogs & Updates}

– Resources –

^{Visual Symptoms Checklist
Comprehensive Visual Evaluation
Second Opinion
Vision Therapy
Causes for Poor Reading
Dyslexia & VT
Prevention
Dizziness, Headaches, Anxiety?}
^{Double Vision}^{College of Optometrists in Vision Development}

– Contact Us –

^{Address:
2353 South Beretania Street
Room 101
Honolulu, Hawaii 96826
Phone: (808) 941-3811
Fax: (808) 951-4063
Email: drclaygushiken@gmail.com}
^{Hours | Direction}

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