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Home » Contact Us » Patient Forms » Teacher Checklist Online

Teacher Checklist Online

Classroom Observation Checklist

Many kinds of vision problems reveal themselves most easily in behavior, posture and attitude. These signs are usually associated most closely with long periods of near visual work. You can easily identify vision problems simply by observing your student and marking this checklist. If your student scores high on this checklist, there is good reason to suspect a vision problem is the cause of poor performance in the classroom.
Name*
First Last
Email*
Date
MM slash DD slash YYYY
Age
After you consider each question, mark the column that applies to the student you are assessing.
Never (0) Seldom (1) Occasionally (2) Frequently (3) Always (4)
Blur when looking at near*

0

1

2

3

4
Double vision, doubled or overlapping words on page*

0

1

2

3

4
Headaches while or after doing near vision work*

0

1

2

3

4
Words appear to run together when reading*

0

1

2

3

4
Burning, itching or watery eyes*

0

1

2

3

4
Frequently rubs eyes*

0

1

2

3

4
Falls asleep or appears sleepy when reading*

0

1

2

3

4
Seeing and visual work is worse at the end of the day*

0

1

2

3

4
Skips or repeats lines while reading*

0

1

2

3

4
Dizziness or nausea when doing near work*

0

1

2

3

4
Head tilts or one eye is closed or covered while reading*

0

1

2

3

4
Difficulty copying from the chalkboard*

0

1

2

3

4
Avoids doing near vision work such as reading*

0

1

2

3

4
Omits (drops out) small words while reading*

0

1

2

3

4
Writes up or down hill*

0

1

2

3

4
Misaligns digits or columns of numbers*

0

1

2

3

4
Reading comprehension low, or declines as day wears on*

0

1

2

3

4
Poor, inconsistent performance in sports*

0

1

2

3

4
Holds books too close, leans too close to computer screen*

0

1

2

3

4
Trouble keeping attention centered on reading*

0

1

2

3

4
Difficulty completing assignments on time*

0

1

2

3

4
First response is “I can’t” before trying*

0

1

2

3

4
Lays head on desk when doing pencil work*

0

1

2

3

4
Does better at math than English, history or social studies*

0

1

2

3

4
Must re-read material several times to grasp its meaning*

0

1

2

3

4
Gets tired quickly when doing reading or homework*

0

1

2

3

4
Avoids sports and games*

0

1

2

3

4
Poor hand/eye coordination, such as poor handwriting*

0

1

2

3

4
Does not judge distances accurately*

0

1

2

3

4
Clumsy, accident prone, knocks things over*

0

1

2

3

4
Does not use or plan his/her time well*

0

1

2

3

4
Does not count or make change well*

0

1

2

3

4
Loses belongings and things*

0

1

2

3

4
Work space is messy or unorganized*

0

1

2

3

4
Fidgety, difficulty sitting still*

0

1

2

3

4
Short attention span, can concentrate on reading work for only a few minutes*

0

1

2

3

4
Daydreams a lot, stares off into the distance frequently*

0

1

2

3

4
Misbehavior has become a problem (to cover up poor school performance) ie. Class clown -‘goofs off’, acts up, moody*

0

1

2

3

4
Extreme emotions, moods change quickly, hyper sensitivity*

0

1

2

3

4
Is more than 1 year behind group in reading-related skills*

0

1

2

3

4
Has poor posture, slouches, slumps in chair, poor muscle tone*

0

1

2

3

4
Forgetful, poor memory*

0

1

2

3

4
TOTAL SCORE
30-40 points = suspect
40 points or more=refer for care
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Thompson Optometry

Unit 3, 470 Chrysler Dr
Brampton, ON L6S 0C1

Phone: 905-793-2020

Email: office@drrickthompson.ca
(Do not send personal health information by email.)

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Thompson Optometry
Unit 3, 470 Chrysler Dr
Brampton, ON L6S 0C1
Phone: 905-793-2020
https://www.drrickthompson.ca

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