Vision Therapy Quiz for Children

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.

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
Seldom = Less than 1 time / month
Occasionally = Less than 1 time / week
Frequently = At least 1 time / week
Always = Everyday

Step 1 of 6 - Before You Start

Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry.
(*) indicates a required field.

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*
MM slash DD slash YYYY
Hidden
Your Age
Country*

The Pattern Glare Test

The image with black and white stripes is called pattern glare. If it causes any negative symptoms such as headaches, strain, discomfort, or if the lines look like they are moving, it is a strong indicator that vision is provoking your symptoms.

If you find this image causes a high level of discomfort to the point that you cannot look at it, this can be an indicator of a visual problem.

patternglare4

Vision Therapy Quiz for Children

Please note: This questionnaire is for those 13 years old or younger.

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:

The Pattern Glare Test

Watch our TEDx video on Vision Therapy

Didn't find what you're looking for? Please let us know where we can improve.