Directions: Children - answer these questions together with your Parents. For every question, select the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question.

• Never = Never

• Occasionally = Less than 1 time / week

• Frequently = At least 1 time / week

• Always = Everyday

Do you have headaches or stomach aches or do you get nervous/anxious at school?*

hile reading or watching video in a car, do you get a headache or stomach ache or feel unwell?*

Do you get sick to your stomach or nauseous on swings or circular rides?*

Do you have difficulty playing sports, or doing gymnastics or dance?*

Do you have trouble catching baseballs or footballs or Frisbees?*

When you are walking, do you bump into people or furniture or door frames?*

Are you anxious or nervous?*

Does it take you a long time to finish your homework?*

Do you have to read the same thing a couple of times to really understand it?*

When reading, do you skip lines or lose your place OR do you use a guide (finger, ruler or a piece of paper) to help you keep your place?*

When you read, does it look like the letters are moving OR does it seem like words are bumping into each other?*

Do bright lights hurt your eyes?*

Do you close or cover one eye to make it easier to see?*

Do you ever see two of everything (double vision)?*

When reading or working on the computer or electronic device, do your eyes feel tired or does your vision get blurry?*

When looking at the blackboard at school, do your eyes feel tired or does your vision get blurry?*

Part 2: Level of Discomfort

On an average day, how much are you bothered by the 8 symptoms listed below?

(Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)

Dizziness*

Nausea*

Anxiety*

Headache*

Neckache*

Unsteady with Walking*

Sensitivity to Light*

Reading Difficulty*

Sound Sensitivity*

Part 3: Previous Diagnosis

Have you ever been diagnosed with...

Learning Disability (LD)*

Lazy Eye*

Migraines or headache?*

Traumatic brain injury or concussion?*

Does your child blink their eyes a lot / much more then most children?*

Are your child’s verbal skills far ahead of their reading skills?*

Has your child ever had an eye operation?*

How did you find us?*

Please tell us a little more about how you found us:

Examples include:

• Internet search: what keywords did you use?

• Referred by a friend or Professional: who specifically referred you?

• Blog or Forum or Social Media: specifically which one was it?

• Other: Please explain | Heard about us - where?

Please provide the most reliable contact information so we can send you your results and best help you.

Name of Parent/Guardian*

Name of Youth*

Age of your Youth*

Complete Address ( County, State, City Zipcode (Postal Code)*

What is the best time of day for one of our team members to call you to discuss your symptoms and answer your questions in the next 2-3 days?*

Parent/Guardian Phone Number*

Email*

So we can send a follow up email with additional information along with your child's test results.