15 & Under Form: Entrance Symptom Checklist Developmental Vision Checklist, please check any that apply Slow reader Points with finger while reading Poor reading comprehension Poor handwriting skills Homework takes longer than it should Short attention span, restless, unable to stay on task Avoids close work Loses place, omits or confuses small words while reading Rubs eyes, squints or blinks excessively Smart in everything but school Substitutes words while reading or copying Difficulty remembering what was read Headache after doing close work Confuses right with left directions repeatedly Feels unusually tired after finishing a visual task Fatigue, frustration, stress Unusual posture/head tilt while reading or writing Double vision Speech/Language Therapy Has repeated grade grade Has an Individual Education Plan (IEP) Resource Room for Tutor for Resource Room for Tutor for Other Print this form
