Symptom Checklist

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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. Carl Garbus, FAAO

Dr. Carl Garbus, FAAO has served patients in Santa Clarita since 1980. The practice is a full scope medical and specialty eye care clinic that emphasizes care for children and adults with vision deficits from traumatic brain injury, stroke and developmental and learning problems. The practice has the latest technology to provide advanced medical eye care services including low vision, specialty contact lenses, myopia management, ocular disease, dry eye and routine eye care/optical.

Dr. Carl Garbus, FAAO has a passion for working with the expanded care team and does extensive work with the leading rehabilitation hospitals around the greater Los Angeles area. He has made various presentations and in-services to optometric societies, occupational therapy groups, and PTA groups regarding vision problems. Another area of interest is working with children who have learning problems. Autism is on the rise and these children have many vision issues that need to be addressed. Dr. Carl Garbus, FAAO serves as the vice president on the board for the Neuro Optometric Rehabilitation Association (NORA) and was the president of the organization in 2010.

Dr. Garbus’s many accomplishments include:

2 term President of NORA (Neuro Optometric Rehabilitation Association)
Awarded the founding father medal from NORA (Neuro Optometric Rehabilitation Association)
Former Chair and long standing member of AOA Vision Rehabilitation Committee
Former president of the Los Angeles County Optometric Society
Member of AOA, COA, NORA
Member of the Academy of optometry FAAO
Hospital privileges and consults at Cedars Sinai Medical Center in Los Angeles, Cottage Hospital in Santa Barbara and Henry Mayo Hospital in Santa Clarita
Works with Centre For Neuro Skills, Solutions At Santa Barbara and the Brain Injury Specialists
Various published articles: Read the articles
Lecturer at AOA (American Optometric Association)

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Testimonials

My eight year old daughter was terrified to go to the eye doctor for fear of her eyes being dilated. The doctor was SO KID friendly! He immediately made her comfortable by engaging her in conversation. It was a geat experience.

Joya B.
Dr. Garbus spent an amazing amount of time to solve my very complicated visual problems. Over the years he has continually achieved results beyond what others felt possible. He is always up to date on the latest science. He is great!

Dolores K.
Family Vision Care Valencia makes it so easy. Staff is knows what they are doing and Dr. Garbus is thorough and kept me well informed during the exam.

Kristy B.
I have been coming to Family Vision Center for almost 20 years. Dr. Garbus has been able to help my vision when other doctors could not. Now my kids see him as well. I highly recommend this office!

Autumn C.
The Doctor is very good. I felt on this visit he seemed rushed. I had questions to ask him but he was already with another patient. I still do not know if my eyes are the same , worse, or better.

Howard B.

Testimonials

My eight year old daughter was terrified to go to the eye doctor for fear of her eyes being dilated. The doctor was SO KID friendly! He immediately made her comfortable by engaging her in conversation. It was a geat experience.

Joya B.

Dr. Garbus spent an amazing amount of time to solve my very complicated visual problems. Over the years he has continually achieved results beyond what others felt possible. He is always up to date on the latest science. He is great!

Dolores K.

Family Vision Care Valencia makes it so easy. Staff is knows what they are doing and Dr. Garbus is thorough and kept me well informed during the exam.

Kristy B.

I have been coming to Family Vision Center for almost 20 years. Dr. Garbus has been able to help my vision when other doctors could not. Now my kids see him as well. I highly recommend this office!

Autumn C.

The Doctor is very good. I felt on this visit he seemed rushed. I had questions to ask him but he was already with another patient. I still do not know if my eyes are the same , worse, or better.

Howard B.

All the staff is friendly, helpful and knowledgeable, and has been for all the years I have been going there.

Mary Ann H.

1 2 3 … 13 Next »

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