Symptom Checklist

Call Us

Vision and Learning Checklist

Please fill out the following checklist to reflect your child or student’s experiences which will provide our behavioural optometrist with a better understanding of your possible concerns pertaining to your child or student’s visual abilities. Rate the following symptoms or scenarios on a scale of 0-4 as it most suitably applies to the patient.

0 = never

1 = rarely

2 = sometimes

3 = frequently

4 = always

The child or caretaker can fill out the questionnaire. If possible, it is recommended for the child to participate, however having a parent or teacher answer the following questions is also a great option.

Please indicate who is filling out the form (you can check more than one option):

Patient

Parent

Teacher

Other

General Questions

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you have a hard time gauging distance accurately?
Do you avoid reading or work that requires material to be up close?
Do you get headaches from work that is close up?
Do you experience motion sickness?
Do you not enjoy sports or find that you have inconsistent performance when participating in sports?
Do you notice that you have to sit close to the computer to see?

When you are reading:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you skip or repeat lines?
Do you see double or blurry?
Do you feel exhausted?
Do you tilt your head or close an eye?
Do you skip small print when reading?
Do you have difficulty with reading comprehension?
Do you read very close up?
Do you find that it is hard to pay attention when reading?
Do you notice that you need to use your finger or something else to keep your place?
Is it easier if you close one eye?
Do you have better reading comprehension when someone else reads to you?

When you are writing:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you confuse or reverse numbers/ letters?
Do you write on an upward or downward slant?
Do you have a hard time writing down answers and you find it easier to answer orally?

General behavior:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you struggle with time management?
Do you say “I can’t do it” before attempting to do so?
Do you bump into things and knock them over?
Do you tend to lose things?
Do you get frustrated often?
Do one or both of your eyes tend to wander in/ out/ up/ down?

Regarding school:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you have a hard time with homework overall?
Is it challenging turning in projects on time?
Do you find it difficult to remember things?
Do you have a hard time looking down at your desk to copy notes from a board?
Do you misnumber rows or columns of numbers?
Do you have a hard time in math class?
Do you benefit from extra help?

20-24 points = suspect for binocular vision problem

> 25 points or more = refer for developmental eye exam

If a child has multiple symptoms or any symptom that occurs always, the child should be assessed by our developmental optometrist. If you are unsure whether the symptoms require a developmental eye exam, please complete this form and our Certified Optometric Vision Therapist will assess the results and contact you with a recommendation of the next steps to take.

Patient First Name

Patient Last Name

Age

Grade

Date

Parent First Name

Parent Last Name

Teacher First Name

Teacher Last Name

Caretaker Occupation

Caretaker First Name

Caretaker Last Name

Email

Phone/Mobile

Take our Vision Quiz to learn whether you should explore Vision Therapy

Dr. Nathaniel Wernick

Dr. Nathaniel (Nat) Wernick, FCOVD, graduated from the Northeastern State University College of Optometry and was selected for Residency training at the State University of New York (SUNY) College of Optometry. As a Resident Optometrist, he specialized in Pediatrics, Vision Therapy, and Traumatic Brain Injury. He has advanced training in developmental optometry and is a Fellow of the College of Optometrists in Vision Development (FCOVD).

Patients visiting Dr. Wernick will receive an in depth examination that extends beyond a comprehensive eye examination with a detailed look at ocular health, vision, contact lens fitting, prescription for eyewear, as well as developmental vision to screen for teaming skills, binocular vision, and visual processing. Dr. Wernick provides full-scope care to patients of all ages including diagnosis and treatment of conditions including red eyes, eye allergies, diabetic and hypertensive eye checks, glaucoma, macular degeneration, dry eyes, eye strain/headaches, and cataracts. Dr. Wernick's advanced training in developmental vision, makes him a sought after provider for pediatric patients, special needs, post concussion, post stroke and sports vision.

Book an Appointment

Learn More

Strabismus Treatment in : Understanding Symptoms, Treatment, Causes, Diagnosis, and Prevention

Early detection and treatment of strabismus is important to prevent further visual problems and maintain good eye health.

Understanding Accommodative Insufficiency: What It Is, Symptoms and Impact on Learning and Work

Accommodative insufficiency causes eyestrain and headaches when focusing on nearby objects. Visit our eye doctor for proper treatment.

1 2 3 … 13 Next »

Testimonials

At Amplify with Dr Wernick I was seeking help for seemingly intractable, probably age-related dryness. I've seen other doctors about it, and that has been helpful, but what he explained to me about it and the careful way he answered all my questions gave me so much more of a clear understanding of what is going on (and is not) that I am more able to implement all his and others' recommendations than I was before. And he gave me additional resources for further follow-up. I am most grateful.

Cynthia Norton

Wow! This is a great Eye Care medical facility. I was thoroughly examined by Dr. Pinkhasov for over 2 hours. She made sure to check my eyes for pretty much everything and patiently explained proper care for my eyes. They definitely know how to provide great care and treat their patients right. Now I know why they have such a great reputation and been around for so long.

Steve Fay

Dr. Kavner is a gifted diagnostician and orthoptic therapist. He treated me several decades ago for a condition similar to dyslexia. I was having migraines five times per week. I worked with him for about a year and I experienced tremendous improvement (down to 3-4 per year) that has lasted.

Mary K.

Dr. Kavner recommended two types of eye therapy for my daughter. One of them using bio-feedback. In just three sessions she is seeing considerably better. She shouted this morning: Ooh my God! I could not see these letters with my glasses on, and now I can see them without my glasses. If you are willing and able to invest in improving your vision, this is a good place to go to!

Peter G.

Dr. Kavner recommended two types of eye therapy for my daughter. One of them using bio-feedback. In just three sessions she is seeing considerably better. She shouted this morning: Ooh my God! I could not see these letters with my glasses on, and now I can see them without my glasses. If you are willing and able to invest in improving your vision, this is a good place to go to!

Kinkie F.

I have always found Dr Kavner's work, expertise and wisdom of the highest caliber. As one of the fathers of OT, occupational othomology, his depth and breadth of knowledge about the eyes' health and wellbeing of the patient is exemplary. Cannot say enough good things about him.

Allen B.

1 2 3 Next »

Blog

Understanding Myopia (nearsightedness): Causes, Symptoms, and Treatment Options

May 30, 2023

Myopia, also known as nearsightedness, is one of the most common vision problems people experience. In this blog post, we'll discuss the causes and symptoms of myopia and how optometrists can help correct this common vision issue. What is Myopia? Myopia is a vision condition in which the eyes focus too close, making distant objects […]

Are Carrots Good for Your Eyes?

May 30, 2023

As an optometrist at Amplify EyeCare Manhattan in New York, one of the most common questions Dr. Nathaniel Wernick often encounters is: "Are carrots good for your eyes?" To put it simply, yes, carrots are indeed beneficial for your eyes. Carrots are known to improve eyesight, and this is largely due to the wealth of […]

picture-focused-serious-young-caucasian-female-teacher-with-textbook-taking-off-glasses-narrowing-eyes-trying-see-something-clearly-student-girl-eyewear-posing-with-diary

Understanding Foggy vision

May 21, 2023

Is foggy vision troubling you? Let our experienced optometrist restore your sight – book an appointment today and see the difference! The term foggy vision often refers to a visual disturbance characterized by blurred, cloudy, or hazy vision, which can make seeing clearly challenging. As your local optometrist, we recognize the significance of maintaining optimal […]

see all blogs