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BY Kathleen Appleby, M.A.

NAME_______________________________ AGE_______ DATE_________

RESPONDENT’S NAME__________________ PHONE_____________________

A one year old child with "normal" visual development can accurately fixate with aligned eyes, smoothly shift gaze, converge eyes to 3" from the nose, and smoothly follow moving objects with no head movement. Acuity continues to improve as the retina matures.

Please complete the above and check any area below that pertains

APPEARANCE

___One eye turns in or out

___Closes an eye or tilts head for near tasks

___Red eyes or lids, or crust on eyelids

___Excessive blinking or tearing of eyes

NEAR & DISTANCE VISUAL ACUITY

___Holds things close to eyes

___Needs to sit close to television to watch it

___Thrusts head forward when looking at distance

LOW CONTRAST SENSITIVITY

___Needs more light to read than expected

___Doesn’t see soil spots on clothes or on counters

___Reads print but can’t see the bus on cloudy days

VISUAL FIELDS

___Difficulty with step downs

___Bumps into things

___Doesn’t read to the end of a sentence before going to the next

ADAPTATION TO LIGHTING CHANGES

___Pauses when coming indoors on sunny days

___Slow adjustment to lighting changes, night travel difficulties

EYE TRACKING

___Head moves instead of eyes when reading or looking at pictures

___Loses place when reading and skips lines

___Needs to use finger as a line marker

___Difficulty solving maze puzzles, i.e., word searches

EYE-TEAMING

___Fatigues during near visual tasks, short interest span

___Difficulty judging where things are in space

___Difficulty following flight of a ball

___Math errors due to misalignment of numbers

___Tires easily, inattentive, poor concentration

Information provided by VISION ASSOCIATES
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