Adult Vision Therapy Questionnaire Adult Vision Therapy Questionnaire Please complete this form and bring it with you to your initial Vision Therapy Evaluation appointment Name* First Last Email* Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Appointment DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Appointment Time : Hours Minutes AM PM AM/PM General Information:Were you referred to our office? Yes No Whom may we thank for this referral?Medical HistoryPhysician Name:ClinicCurrent Medications:Are you generally healthy? Yes No If no, please explain:Has a neurological evaluation been performed? Yes No By whom?When?Results/Recommendations:Has a psychological evaluation been performed? Yes No By whom?When?Results/Recommendations:Has an occupational therapy evaluation been performed? Yes No By whom?When?Results/Recommendations:Is there a history of:FamilyPatientDiabetesGlaucomaHigh Blood PressureLearning DisabilityAmblyopia (lazy eye)Multiple SclerosisEpilepsy or SeizuresBrain TumorOtherVisual HistoryHas your vision been previously evaluated? Yes No Doctor's Name:Reason for examination:Results and recommendations:Were glasses or contact lenses prescribed?Do you wear them constantly? Yes No If no, when do you wear them?Present SituationIn what ways are you having visual difficulty?Difficulty ReadingHeadachesDifficulty with workEye Turn/StrabismusLazy Eye/AmblyopiaOther Diagnosed Vision ProblemHow long has this problem/difficulty been observed?Do you experience any of the following? Headaches Yes No If yes, when?Blurred vision/in and out of focus Yes No If yes, when?Double vision Yes No If yes, when?Eyes hurt Yes No If yes, when?Eyes tired Yes No If yes, when?Words move around on the page Yes No If yes, when?Motion sickness/carsickness Yes No If yes, when?Dizziness Yes No If yes, when?Please list any other complaints concerning your vision:Have you ever noticed the following?Frequent eye rubbing? Yes No If yes, when?Bothered by light Yes No If yes, when?Frequent blinking Yes No If yes, when?Closing or covering one eye Yes No If yes, when?Difficulty seeing distant objects Yes No If yes, when?Head close to paper when reading/writing Yes No If yes, when?Avoiding reading Yes No If yes, when?Tilting head when reading Yes No If yes, when?Moving head when writing Yes No If yes, when?Confusing letters or words Yes No If yes, when?Reversing letters or words Yes No If yes, when?Confusing left and right Yes No If yes, when?Skipping - rereading or omitting word Yes No If yes, when?Losing place while reading Yes No If yes, when?Vocalizing when reading silently Yes No If yes, when?Reading slowly Yes No If yes, when?Using finger as a marker Yes No If yes, when?Poor reading comprehension Yes No If yes, when?Comprehension decreases over time Yes No If yes, when?Writing neatly but slowly Yes No If yes, when?Frequent erasures Yes No If yes, when?Tiring easily Yes No If yes, when?Difficulty recognizing same word Yes No If yes, when?Difficulty with memory Yes No If yes, when?Remembering better what is heard vs. seen Yes No If yes, when?Responding better orally than by writing Yes No If yes, when?Avoiding near tasks Yes No If yes, when?Short attention span/losing interest Yes No If yes, when?Does your job include the use of a video terminal? Yes No Hours per dayDid you like school?Was a grade repeated?Which one?Was your work average?Better than average?Below average?How do you like to spend your free time?How many hours a day do you: Use a computerReadWatch TVPlay video games?Are you involved in sports? Yes No Which one(s)How oftenIs there any other information you would like to share that you feel would be helpful/important in our treatment?Vision TherapyHave you heard about Vision Therapy before? Yes No Have you had any other Vision Therapy Evaluations? Yes No If yes, when?Was therapy prescribed?Thank you for your careful completion of this important form. The detailed information you supplied allows for a more comprehensive evaluation, allowing us to better meet your visual needs. I am looking forward to meeting you and helping you with your visual concerns. Δ
