The First Visual-Behavioral Screening on the Internet

Questionnaire for Visual Problems and Efficiency in near work or study

Answering the questions below, you get the results of your visual-behavioral status directly to your mailbox E-Mail.

The questionnaire should be completed according to the answers given by the person that follow the children (if they can't answer).

Please enter more data as possible to allow the sending of the response in the proper order. You will need a bit 'of time...but it will be worth it !


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

Now you can answer in a realistic and relevant manner, the following questions

  1. After having read or studied you often have bloodshot eyes?YesNot

  2. During the study or reading often feel internal tension in the eyes?Yes Not

  3. During the study or reading often feel burning eyes?Yes Not

  4. During the study or reading feel weeping eyes?Yes Not

  5. Sometimes, during study or working at close distance, do you see blurred images?Yes Not

  6. Sometimes, do you see a double image during reading or working at close distance?Yes Not

  7. Do you often complain headaches after close work or study?Yes Not

  8. If yes, what side of the head? (F = Front, T = Temple, P = Posterior/Rear)Localized F-T-P or Generalized

  9. If yes, have you the same headaches during holidays?Not Yes

  10. After work at close distance, do you suffer from nausea or dizziness?Yes Not

  11. When reading or studying can you stay focused?Yes Not

  12. At what distance you hold the material to read or write:From 10 to 29 cm. From 30 to 50 Cm.

  13. After reading for a certain time, the vision for far becomes clear:Slowly Quickly

  14. During a period of relaxation, vision at far distance::Increase Remain the same

  15. Usually do you turn your head sideways when studying or reading?Yes Not

  16. Sometime do you prefer to read with one eye only?Yes Not

  17. The line is easy to follow without aid (finger, pen, etc..)?Not Yes

  18. Do you make frequent errors in spelling?Yes Not

  19. Are you ordered in writing and drawing?Not Yes

  20. Do you have to study a lot, perhaps more than necessary?Yes Not

  21. Your school or work performance is:Insufficient Good

  22. When reading, do you tend to reverse letters, syllables, words?Yes Not

  23. Do you easily understand what you have to study or learn?Not Yes

  24. Do you ever easy to confuse the right and left?Yes Not

  25. 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: