Vision Therapy Quiz for Adults Vision Therapy Quiz for Adults Please note: This questionnaire is for those 14 years old or older. If you are 13 years old or younger, please click here. If you would like to tell us more about your symptoms, please write about them in the Comment Section at the end of the Questionnaire. We will combine this information with the responses you gave in the Questionnaire to provide you with a more detailed interpretation of the results. Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry. (*) indicates a required field. Directions: For each of the following questions, please check the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question. •Never = Never •Occasionally = Less than 1 time / week •Frequently = At least 1 time / week •Always = Everyday Symptoms*AlwaysFrequentlyOccasionallyNever1. Do you have headaches and / or facial pain?Symptoms*AlwaysFrequentlyOccasionallyNever2. Do you have pain in your eyes with eye movement? Symptoms*AlwaysFrequentlyOccasionallyNever3. Do you experience neck or shoulder discomfort?Symptoms*AlwaysFrequentlyOccasionallyNever4. Do you have dizziness and / or lightheadedness? Symptoms*AlwaysFrequentlyOccasionallyNever5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?Symptoms*AlwaysFrequentlyOccasionallyNever6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you feel unsteady with walking, or drift to one side while walking? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you feel overwhelmed or anxious when in a crowd? Symptoms*AlwaysFrequentlyOccasionallyNeverDoes riding in a car make you feel dizzy or uncomfortable?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience anxiety or nervousness because of your dizziness? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you ever find yourself with your head tilted to one side?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience poor depth perception or have difficulty estimating distances accurately? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience double / overlapping / shadowed vision at far distances?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience double / overlapping / shadowed vision at near distances? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience glare or have sensitivity to bright lights?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you close or cover one eye with near or far tasks? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you tire easily with close-up tasks (computer work, reading, writing)? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you blink to clear up distant objects after working at a desk or working with close-up activities (i.e. - computer work, reading, writing)?Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience words running together with reading? Symptoms*AlwaysFrequentlyOccasionallyNeverDo you experience difficulty with reading or reading comprehension? Level of Discomfort*On an average day, how much are you bothered by the 8 symptoms listed below? (Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)012345678910DizzinessNauseaAnxietyHeadacheNeckacheUnsteady with WalkingSensitivity to LightReading Difficulty History*Have you ever been diagnosed with:YesNoTraumatic brain injury or concussion (TBI)?Reading disability?Lazy Eye?Have you ever had an eye operation? Does the image below bother you?YesNo Can we contact you about your results?*YesNoComment SectionIf you want to tell us more about you symptoms, or if you have specific questions, record them here:Please help us help others by using this box to be very specific about how you found usPlease tell us how you found us?*Internet SearchReferred by a friendReferred by a professionalFound us in a forum, blog or social mediaExplain:*Examples include: If you found us by Internet search, what key words did you use? If you were referred, who specifically referred you? If you found out about us on a blog or forum or social media site, specifically which one was it? Other: Please explain | Heard about us - where?To help us better serve you, please provide the following information:Have You Been To The Practice Before?*New PatientReturning PatientChoose a Location*-Select-Nanaimo, BCVictoria, BCPlease select the location that is nearest you.Name* First Last Email* Best Phone Number*Back-up Phone Number*Date of Birth* Date Format: MM slash DD slash YYYY Your Age--Please Select--1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100100+Country*--Please Select--CanadaUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe