Student: Observation Date(s):

Visual

__ Difficulty with or avoidance of tasks requiring concentration, memory, reading or problem solving

__ Poor memory or concentration, trouble with spelling, vocabulary and grammar or inability to complete work during a given time frame

__ Complains of headache associated with near work

__ Complains of double vision or of blurry vision (far or near)

__ Covers or closes one eye when reading or doing near tasks

__ Complains of discomfort or inability to learn in tasks demanding consistent attention to fine detail

__ Tilts head extremely or works to one side of desk

__ Either eye turns in or out

__ Rubs eyes or forehead frequently

Visual-Motor

__ Poor physical or athletic performance (particularly poor spatial awareness)

__ Holds reading material very close to face

__ Writes in small, cramped style

__ Makes frequent errors in copying

__ Complains of words or letters jumping around

__ Loses place while reading

__ Uses finger to keep place

__ Handwriting is sloppy

__ Easily frustrated trying to draw figures

Reading/Language

__ Reverses letters or words

__ Omits words/letters when reading or writing

__ Spells poorly

__ Tires easily when reading

__ Performs below ability level for no obvious reason

Attention

__ Trouble sitting still; fidgets frequently

__ Poor attention to reading

__ Responds to directions poorly

__ Behavior problems (particularly those related to frustration in the learning environment)

__ Displays tiredness or lethargy during the school day

__ Indifference to academic satisfaction and/or classroom work performance; and/or expressions of discouragement related to schoolwork

__ Trouble remembering or relating to material that is read