Name: Neuro Visual Performance
Address: 734 Caledonia Ave, Victoria, BC, V8T 1E5, CA
Telephone: 1-250-590-7384
Price range: $000 - $300

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*
Always Frequently Occasionally Never
1. Do you have headaches and / or facial pain?
Symptoms*
Always Frequently Occasionally Never
2. Do you have pain in your eyes with eye movement?

Symptoms*
Always Frequently Occasionally Never
3. Do you experience neck or shoulder discomfort?
Symptoms*
Always Frequently Occasionally Never
4. Do you have dizziness and / or lightheadedness?

Symptoms*
Always Frequently Occasionally Never
5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?
Symptoms*
Always Frequently Occasionally Never
6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?

Symptoms*
Always Frequently Occasionally Never
Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?
Symptoms*
Always Frequently Occasionally Never
Do you feel unsteady with walking, or drift to one side while walking?

Symptoms*
Always Frequently Occasionally Never
Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?
Symptoms*
Always Frequently Occasionally Never
Do you feel overwhelmed or anxious when in a crowd?

Symptoms*
Always Frequently Occasionally Never
Does riding in a car make you feel dizzy or uncomfortable?
Symptoms*
Always Frequently Occasionally Never
Do you experience anxiety or nervousness because of your dizziness?

Symptoms*
Always Frequently Occasionally Never
Do you ever find yourself with your head tilted to one side?
Symptoms*
Always Frequently Occasionally Never
Do you experience poor depth perception or have difficulty estimating distances accurately?

Symptoms*
Always Frequently Occasionally Never
Do you experience double / overlapping / shadowed vision at far distances?
Symptoms*
Always Frequently Occasionally Never
Do you experience double / overlapping / shadowed vision at near distances?

Symptoms*
Always Frequently Occasionally Never
Do you experience glare or have sensitivity to bright lights?
Symptoms*
Always Frequently Occasionally Never
Do you close or cover one eye with near or far tasks?

Symptoms*
Always Frequently Occasionally Never
Do 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*
Always Frequently Occasionally Never
Do you tire easily with close-up tasks (computer work, reading, writing)?

Symptoms*
Always Frequently Occasionally Never
Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?
Symptoms*
Always Frequently Occasionally Never
Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?

Symptoms*
Always Frequently Occasionally Never
Do 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*
Always Frequently Occasionally Never
Do you experience words running together with reading?

Symptoms*
Always Frequently Occasionally Never
Do 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)
0 1 2 3 4 5 6 7 8 9 10
Dizziness
Nausea
Anxiety
Headache
Neckache
Unsteady with Walking
Sensitivity to Light
Reading Difficulty

Does the image below bother you?
- Yes
- No

Can we contact you about your results?*
- Yes
- No
Comment Section
If 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 us
Please tell us how you found us?*
- Internet Search
- Referred by a friend
- Referred by a professional
- Found us in a forum, blog or social media
Explain:*
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 Patient
- Returning Patient
Choose a Location*
Please 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
Country*

	Yes	No
Traumatic brain injury or concussion (TBI)?
Reading disability?
Lazy Eye?
Have you ever had an eye operation?

Vision Therapy Quiz for Adults

Vision Therapy Quiz for Adults

Please help us help others by using this box to be very specific about how you found us

To help us better serve you, please provide the following information:

Follow Us

Victoria Office

Nanaimo Office

	0	1	2	3	4	5	6	7	8	9	10
Dizziness
Nausea
Anxiety
Headache
Neckache
Unsteady with Walking
Sensitivity to Light
Reading Difficulty