Questionnaire for Vision Therapy

Experience the benefits of vision therapy! Download the form or fill it out below to get started.

Visual History

Is this your child’s first eye examination?

Please check any of the following that you have noticed or that your child complains about:

Educational History

Has your child repeated any grades?

Please check if your child has difficulties in any of the following areas:

Please check if any of the following aspects of reading are difficult or are behaviors you have noted during reading:

Do you feel your child is performing up to their potential in school?

Does your child enjoy reading for pleasure?

Developmental History

Has your child repeated any grades?

Was your child born prematurely?

Medical History

Has your child had any severe childhood illnesses, hospitalizations, injuries, or physical impairments?

Any current health problems?

Family History

Does anyone in the family have any of the following?

Helpful Articles