COVD Quality of Life Assessment QUALITY OF LIFE SYMPTOM CHECKLIST*Patient's Name* First Last Date* MM slash DD slash YYYY 1. Blur when looking at near* Never Seldom Occasionally Frequently Always 2. Double Vision* Never Seldom Occasionally Frequently Always 3. Headaches with near work* Never Seldom Occasionally Frequently Always 4. Words run together when reading* Never Seldom Occasionally Frequently Always 5. Burning, itchy, watery eyes* Never Seldom Occasionally Frequently Always 6. Falls asleep reading* Never Seldom Occasionally Frequently Always 7. Sees worse at the end of the day* Never Seldom Occasionally Frequently Always 8. Skips/repeats lines when reading* Never Seldom Occasionally Frequently Always 9. Dizziness/nausea with near work* Never Seldom Occasionally Frequently Always 10. Head tilt/closing one eye when reading* Never Seldom Occasionally Frequently Always 11. Difficulty copying from chalkboard* Never Seldom Occasionally Frequently Always 12. Avoids near work/reading* Never Seldom Occasionally Frequently Always 13. Omits small words when reading* Never Seldom Occasionally Frequently Always 14. Writes uphill/downhill* Never Seldom Occasionally Frequently Always 15. Misaligns digits/columns of numbers* Never Seldom Occasionally Frequently Always 16. Reading comprehension down* Never Seldom Occasionally Frequently Always 17. Poor/inconsistent in sports* Never Seldom Occasionally Frequently Always 18. Holds reading too close* Never Seldom Occasionally Frequently Always 19. Trouble keeping attention on reading* Never Seldom Occasionally Frequently Always 20. Difficulty completing assignments on time* Never Seldom Occasionally Frequently Always 21. Always says "I can't" before trying* Never Seldom Occasionally Frequently Always 22. Avoids sports/games* Never Seldom Occasionally Frequently Always 23. Poor hand-eye (poor handwriting)* Never Seldom Occasionally Frequently Always 24. Does not judge distance accurately* Never Seldom Occasionally Frequently Always 25. Clumsy, knocks things over* Never Seldom Occasionally Frequently Always 26. Does not use his/her time well* Never Seldom Occasionally Frequently Always 27. Does not make change well* Never Seldom Occasionally Frequently Always 28. Loses belongings/things* Never Seldom Occasionally Frequently Always 29. Car/motion sickness* Never Seldom Occasionally Frequently Always 30. Forgetful/poor memory* Never Seldom Occasionally Frequently Always This field is hidden when viewing the formNumber*Checklist is from the College of Optometrists in Vision Development www.covd.org Δ
