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Visionary of the Month

Home » Contact Us » ESTABLISHED PATIENT VISION QUESTIONNAIRE

ESTABLISHED PATIENT VISION QUESTIONNAIRE

PATIENT NAME

First Last

DATE:

MM slash DD slash YYYY

PRESENT SITUATION

Do you experience any of the following symptoms?

Headaches

Yes

No

When?

Blurred vision

Yes

No

When?

Double vision

Yes

No

When?

Eyes tired

Yes

No

When?

Eyes hurt

Yes

No

When?

Motion sickness/car sickness

Yes

No

when?

Frequent sties

Yes

No

When?

Red or bloodshot eyes

Yes

No

When?

Watery eyes

Yes

No

When?

Bothered by light/light sensitivity

Yes

No

When?

Closing or covering an eye to see better

Yes

No

When?

Need to hold paper close when reading or writing

Yes

No

When?

Head tilt

Yes

No

When?

Confusion of letters or words

Yes

No

when?

Skipping or omitting words

Yes

No

When?

Loss of place when reading

Yes

No

when?

Need to use finger to keep place

Yes

No

When?

Head moves when reading

Yes

No

when?

Silent vocalization/moving lips while reading

Yes

No

When?

Confusion of what is being seen or read

Yes

No

When?

Letters or words appear to move or float around when reading

Yes

No

When?

Difficulty aligning columns of numbers

Yes

No

When?

Poor reading comprehension

Yes

No

When?

Comprehension decrease over time

Yes

No

When?

Falling asleep when reading

Yes

No

When?

Writes or prints poorly

Yes

No

When?

Can respond better orally than in writing

Yes

No

When?

Tires easily

Yes

No

When?

Difficulty with short term memory

Yes

No

When?

Difficulty with long term memory

Yes

No

When?

Short attention span or loss of interest

Yes

No

When?

Difficulty attending to detail

Yes

No

When?

Poor/awkward general motor coordination

Yes

No

When?

Poor fine motor coordination

Yes

No

When?

Difficulty judging distances

Yes

No

When?

Difficulty driving

Yes

No

When?

Dislike/avoid sports

Yes

No

When?

Nausea associated with visual tasks

Yes

No

When?

Halos around light

Yes

No

When?

Tilt head during desk work

Yes

No

When?

Squinting, covering or closing one eye

Yes

No

When?

Postural changes when doing desk work

Yes

No

When?

Need for very bright light or dim light when reading

Yes

No

When?

Loss of interest or short attention span for close work

Yes

No

When?

Difficulty sustaining reading or writing

Yes

No

When?

General or visual fatigue at the end of the day

Yes

No

When?

Poor time management

Yes

No

When?

Inconsistent performance in work or sports

Yes

No

When?

Difficulty hitting or judging moving targets during sports

Yes

No

When?

List any other complaints you have concerning vision:

Have you had any eye exams elsewhere since your last visit here?

Yes

No

for what reason, and with whom?

What is the primary reason you are seeking a vision evaluation today?

Current health status:

List medications and conditions they are taken for:(Required)

List any allergies to food or medications:

Privacy Policy

Health Information Protection(Required)

I have read and agree to the Privacy Policy

Signature(Required)

Date(Required)

MM slash DD slash YYYY

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The Center for Vision Development

Phone: 512-329-8900

5656 Bee Caves Rd, Building D, Suite 201
Austin, TX 78746

Monday: 9:00 AM - 7:00 PM
Tuesday: 9:00 AM - 7:00 PM
Wednesday: 9:00 AM - 7:00 PM
Thursday: 9:00 AM - 7:00 PM
Friday: 9:00 AM - 6:00 PM
Saturday: Closed
Sunday: Closed

The Center for Vision Development

Phone: 512-329-8900

4949 Franklin Ave, Suite 309B
Waco, TX 76710

Monday: Closed
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Friday: Closed
Saturday: Closed
Sunday: Closed

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Disclaimer
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The Center for Vision Development
5656 Bee Caves Rd, Building D, Suite 201
Austin, TX 78746
Phone: 512-329-8900
https://www.visiontherapyaustin.com

The Center for Vision Development
4949 Franklin Ave, Suite 309B
Waco, TX 76710
Phone: 512-329-8900
https://www.visiontherapyaustin.com

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