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Vision Therapy Online Test
Complete this test to find out if you or your child may benefit from Vision Therapy.
8
Questions
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1
Current Grade Level
*
This field is required.
Current grade level or the grade they will be entering in the next semester.
Kindergarten
First Grade (1st)
Second Grade (2nd)
Third Grade (3rd)
Fourth Grade (4th)
Fifth Grade (5th)
Sixth Grade (6th)
Seventh Grade (7th)
Eighth Grade (8th)
Ninth Grade (9th)
Tenth Grade (10th)
Eleventh Grade (11th)
Twelfth Grade (12th)
College
Everyone outside of college
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2
Is there any evidence from the school or a psychological test that some visual difficulties may be present?
If so, what? Please explanation.
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Small
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quote
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Ok
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3
Have you noticed, or your child reported any of the following?
*
This field is required.
Select all that apply
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Holding reading or writing materials too close
Closing or covering one eye
Eyes frequently reddened
Frequent eye rubbing
Excessive blinking
Frequent styes
Tilting head when reading or writing
Moves head when reading, instead of eyes, to follow the words.
Uses finger as a marker
Confuses letters/ words
Reverses letters or words
Skips, re-reads or omits words or lines
Vocalizes or lips words when reading silently
Reads slowly
Poor reading comprehension
Tires easily
Short attention span
Poor penmanship
Poor general coordination
Bothered by light
Inability to see distant objects
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4
Name
Patient's Name
First Name
Last Name
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5
Phone Number
By submitting, you agree to receiving a call regarding your results.
ex. (123)456-7890
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6
Email
By submitting you agree to receiving an email regarding your submission and any future vision therapy information, you can opt out using the link in the email. We do NOT sell email addresses to a third party.
example@example.com
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7
We'd like to contact you regarding your results. Should we call or email?
Call
Email
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8
Please verify that you are human
*
This field is required.
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9
Here's your score!
We recommend, with a score of one (1) or higher, that you contact us to discuss your concerns with our Developmental Optometrist.
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