Visual Processing Disorder Evaluation Form.
Please complete this evaluation to assist in the assessment of visual processing disorder symptoms and their impact.
Patient Initials or Code
*
Age Group
*
Please Select
Child (0-12)
Adolescent (13-17)
Adult (18-64)
Older Adult (65+)
Primary Reason for Evaluation
*
Academic difficulties
Occupational challenges
Behavioral concerns
Other
History of Visual Processing Difficulties
*
No prior concerns
Previous diagnosis
Suspected but not diagnosed
Please rate the severity of the following symptoms in the past month.
*
Rows
Never
Rarely
Sometimes
Often
Always
Loses place while reading
1
2
3
4
5
Difficulty copying from board/paper
6
7
8
9
10
Problems with visual memory
11
12
13
14
15
Difficulty recognizing shapes/letters
16
17
18
19
20
Trouble with visual-motor tasks
21
22
23
24
25
How much do visual processing difficulties impact daily activities?
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
Academic or Occupational Performance (choose one)
*
No difficulties
Mild difficulties
Moderate difficulties
Severe difficulties
Previous Interventions or Assessments
*
Vision therapy
Occupational therapy
Educational support
No previous interventions
Other
Family History of Visual Processing Difficulties
*
Yes
No
Unknown
Referral Source
*
Please Select
Self
Parent/Guardian
Teacher
Healthcare provider
Other
Submit Evaluation
Should be Empty: