Vision Therapy History
List significant illnesses, bad falls, high fevers or chronic illnesses:
During pregnancy of this child, did any of the following occur:
My child is:
Skills / Milestones
Has your child undergone any of the following testing / treatment/ therapy?
Do you observe or does your child report any of the following?
Strabismus / Amblyopia History
What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?
Brain Injury Vision Symptom Survey
Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4
If you experience any of the symptoms below, please check if the symptom was present before the injury or only after:
Dry Eye History
Over the past week, which of the following eye symptoms have you experienced?
Reading and Computer Symptom Checklist
CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)
Please answer the following questions about how your eyes feel when reading or doing close work.
NOTE: if the patient is a child, please read the instructions and then each item exactly as written.
Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4
Check All That Apply:
Dizziness And Motion Sensitivity Checklist