Any of the following symptoms may indicate a functional vision problem. Please mark the symptoms that occur and use the scoring criteria which will automatically calculate at the bottom of the page to determine if a functional vision evaluation is recommended. If you would like to schedule an evaluation, please make note of your score as you will need this when scheduling.

SymptomChecklist500

Criteria:

  • 15-20 points total = Possible functional vision problems
  • 21-30 points total = Probable functional vision problems
  • Over 30 points total = Definite functional vision problems
  • 15+ total points = Functional vision evaluation recommended

Symptom Checklist