Strathpine
345 Gympie Road
Strathpine
(07) 3205 1593

Caboolture
Shop 27a Caboolture Square Shopping Centre
60-78 King Street
Caboolture
(07) 5495 2316

You are here:Links > Teacher Questionnaire

    Grade 1-6 Teacher Pre-Exam Questionnaire

    We have been asked to do a visual assessment on this child. As visual development and general development are inter-related, it would be helpful to our assessment if you could fill in the following questionnaire on your observations.


    Authorisation

    I grant permission for the release of confidential information regarding the below child to RA Optometrists.


    School Information


    Child’s Information (Confidential)

    YesNo


    Observations

    Teachers usually have had the opportunity to observe the child in different situations and note any difficulty. The following is a checklist of symptoms which have been found to be frequently associated with a vision problem. Please read through this list and check those items you have noticed in this child's case.

    READING
    Fatigue with reading
    Comprehension poorer with time
    Confusion of similar words or letters
    Fails to recognise same word in next sentence
    Rubs eyes during and after reading
    Skips words or sentences
    Rereads lines or phrases
    Reads too slowly for age
    Poor ability to remember what is read
    Complains of letters or lines "running together", "jumping around", or "swimming"
    Complains of blur while reading
    Repeatedly omits small words
    Holds reading close
    Reverses words
    Moves head while reading

    GENERAL BEHAVIOUR
    Complains of headaches
    Dislikes tasks requiring sustained visual concentration
    Irritability or restlessness after close work
    Daydreaming or inattentiveness
    Blinks excessively
    Frowns, scowls or squints
    Covers or closes one eye
    Avoids close work
    Complains of double vision
    Tilts head to one side
    Rubs eyes frequently

    WRITING OR OTHER DESK TASKS
    Holds head too close to desk when writing
    Difficulty copying from whiteboard
    Difficulty copying from book
    Slowness in copying from whiteboard
    Slowness in copying from book
    Writes crookedly and/or poorly spaced
    Reverses letters and/or numbers
    Poor eye/hand co-ordination
    Writes up or down hill on paper
    Misaligns horizontal and vertical series of numbers

    APPEARANCE OF EYES
    Eye turning in
    Eye turning out
    Watering eyes
    Bloodshot eyes
    Red rimmed, crusted or swollen lids
    Frequent sties

    BODY POSTURE AND SPACE AWARENESS
    Unusual awkwardness
    Frequent tripping or stumbling
    Confuses right or left directions
    Improper or awkward posture while writing
    Improper or awkward posture while reading