Vision Therapy Patient/Parent Survey

Patient Name *

First Name

Last Name

Guardian Name

First Name

Last Name

Phone

(###)

###

####

Physical Signs *

One eye turning in or out

Squinting, eye rubbing or excessive blinking

Blurred or Double Vision

Headaches or Dizziness after reading

Head Tilting, closing or blocking one eye when reading

Performance Signs *

Avoids "near" work

Frequent loss of place when reading

Omits, inserts, or rereads letters/words

Confuses similar looking words

Failure to recognize the same word in the next sentence

Poor reading comprehension

Letter or word reversals after the first grade

Difficulty copying from the chalkboard

Poor handwriting; misaligns numbers

Book held too close to the eyes

Secondary Symptoms

Smart in everything but school

Low self-esteem, poor self image

Temper flare-ups, aggressiveness

Short Attention Span

Fatigue, frustration, stress

Irritability