Please indicate how often these symptoms are experienced by you or your child.

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How often do you get headaches with near work (such as reading)?
How often do words run together while reading?
How often do you get burning, itching, or watery eyes?
How often do lines skip or repeat while reading?
How often do you tilt your head or close one eye while reading?
How often do you have difficulty copying from the board?
How often do you avoid near work (such as reading)?
How often do you omit small words while reading?
How often does your writing drift uphill and/or downhill?
How often do you misalign digits and/or columns of numbers?
How often do you experience poor reading comprehension?
How often do you hold books or near work too close to your eyes?
How often do you have a short attention span with near work (like reading)?
How often do you have difficulty completing assignments on time?
How often do you say "I can't" before trying something?
How often do you knock things over or feel "clumsy"?
How often do you feel you use your time poorly or have poor time management?
How often do you lose your belongings or misplace things?
How often do you forget things or feel you have a poor memory?
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