Questions about lower visual field	Never	Rarely	Sometimes	Often	Always	NA
Does your child…
1. trip over toys and obstacles on the floor?
2. have difficulty walking down stairs?
5. appear to ‘get stuck’ at the top of a slide/hill?
6. look down when crossing floor boundaries e.g. where tiles meet the soil?
7. When walking, does your child hold onto your clothes, tugging down?
8. Does your child find uneven ground difficult to walk over?
9. Does your child bump into low furniture such as a teapoy?
10. Does your child get angry if furniture is moved?
Questions about visual field on the sides
Does your child…
11. have difficulty finding the beginning of a line when reading?
12. have difficulty finding the next word when reading?
13. walk out in front of traffic?
If so, which side?	right/	left/	both
14. bump into doorframes or partly open doors?
If so, which side?	right/	left/	both
15. miss pictures or words on one side of a page?
If so, which side?	right/	left/	both
Questions about motion perception	Never	Rarely	Sometimes	Often	Always	NA
Does your child…
16. have difficulty seeing scenery from a moving vehicle?
17. have difficulty seeing things which are moving quickly, such as small animals?
18. avoid watching fast moving TV?
19. choose to watch slow moving TV?
20. have difficulty catching a ball?
Questions about difficulty in seeing when there is too much to see	Never	Rarely	Sometimes	Often	Always	NA
Does your child…
21. have difficulty seeing something which is pointed out in the distance?
22. have difficulty finding a close friend or relative who is standing in a group?
23. have difficulty finding an item in a supermarket e.g., finding the breakfast cereal they want?
24. get lost in places where there is a lot to see, e.g., a crowded shop?
25. get lost in places which are well known to them?
26. have difficulty locating an item of clothing in a pile of clothes?
27. have difficulty selecting a chosen toy in a toy box?
28. want to sit closer to the television than about 30 cm?
29. find copying words or drawings time- consuming and difficult?
30. Do quiet places/open countryside cause difficult behaviour?
31. Is behaviour in a busy supermarket or shopping centre difficult?
Seeing when competing sensory stimuli present	Never	Rarely	Sometimes	Often	Always	NA
32. After being distracted does your child find it difficult to get back to what they were doing?
33. Does your child bump into things when walking and having a conversation?
34. Does your child miss objects which are obvious to you because they are different from their background and seem to ‘pop out’ e.g., a bright ball in the grass?
Activities with sustained near vision task	Never	Rarely	Sometimes	Often	Always	NA
35. Does your child react angrily when other restless children cause distraction?
36. Does your child find it difficult to concentrate on a sustained near vision task for more than 5 min?
Difficulties in recognition and visual memory	Never	Rarely	Sometimes	Often	Always	NA
Does your child…
37. have difficulty recognising close relatives in real life?
38. have difficulty recognising close relatives from photographs?
39. mistakenly identify strangers as people known to them?
40. have difficulty understanding the meaning of facial expressions?
41. have difficulty naming common colours?
42. have difficulty naming basic shapes such as squares, triangles and circles?
43. have difficulty recognising familiar objects such as the family car?