Name: Opto-mization NeuroVisual Performance Vision Therapy
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 13 years old or younger.
If you are 14 years old or older, 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
•Sometimes = At least 1-3 time / week
•Often = More than 3 times / week

Symptoms*
Never Sometimes Often
1. Has trouble keeping centered on reading.*
Symptoms*
Never Sometimes Often
2. Has difficulty completing tasks or homework on time.
Symptoms*
Never Sometimes Often
3. Skips or repeats lines while reading.
Symptoms*
Never Sometimes Often
4. Loses belongings or things.

Symptoms*
Never Sometimes Often
5. Reading comprehension low, or declines as day wears on.
Symptoms*
Never Sometimes Often
6. Reverses letters, numbers, or confuses similar words.
Symptoms*
Never Sometimes Often
7. Avoids doing near work such as reading.
Symptoms*
Never Sometimes Often
8. First response is "I can't" before trying.

Symptoms*
Never Sometimes Often
9. Is clumsy, accident prone, knocks things over.
Symptoms*
Never Sometimes Often
10. Has forgetful, poor memory.

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
Name*
First Last
Choose a Location*
Please select the location that is nearest you.
Email*
Best Phone Number*
Back-up Phone Number*
Date of Birth*
Date Format: MM slash DD slash YYYY
Your Age
Country*

Vision Therapy Quiz for Children

Step 1 of 6 - Before You Start

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:

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Opto-mization NeuroVisual Performance Vision Therapy

Opto-mization NeuroVisual Performance Vision Therapy