The questionnaire should be completed according to the answers given by the person that follow the children (if they can't answer).
First Name, Last Name or Initials (Mandatory)
Your Address
Yaou Post code
Your Town
Your E-Mail Address (Mandatory)
Your Usual Occupation (Recommended)
Your main hobby that you care very often
Glasses Contact Lenses
Ever Only for far distance Only to read and/or study
After having read or studied you often have bloodshot eyes?YesNot
During the study or reading often feel internal tension in the eyes?Yes Not
During the study or reading often feel burning eyes?Yes Not
During the study or reading feel weeping eyes?Yes Not
Sometimes, during study or working at close distance, do you see blurred images?Yes Not
Sometimes, do you see a double image during reading or working at close distance?Yes Not
Do you often complain headaches after close work or study?Yes Not
If yes, what side of the head? (F = Front, T = Temple, P = Posterior/Rear)Localized F-T-P or Generalized
If yes, have you the same headaches during holidays?Not Yes
After work at close distance, do you suffer from nausea or dizziness?Yes Not
When reading or studying can you stay focused?Yes Not
At what distance you hold the material to read or write:From 10 to 29 cm. From 30 to 50 Cm.
After reading for a certain time, the vision for far becomes clear:Slowly Quickly
During a period of relaxation, vision at far distance::Increase Remain the same
Usually do you turn your head sideways when studying or reading?Yes Not
Sometime do you prefer to read with one eye only?Yes Not
The line is easy to follow without aid (finger, pen, etc..)?Not Yes
Do you make frequent errors in spelling?Yes Not
Are you ordered in writing and drawing?Not Yes
Do you have to study a lot, perhaps more than necessary?Yes Not
Your school or work performance is:Insufficient Good
When reading, do you tend to reverse letters, syllables, words?Yes Not
Do you easily understand what you have to study or learn?Not Yes
Do you ever easy to confuse the right and left?Yes Not
Do you remember with ease textbooks or readings?Not Yes
It's now very important you include your comments, especially about what drove you to fill out the questionnaire and what solution you are looking for: