Vision Therapy Quiz for Children Step 1 of 6 - Before You Start 16% 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*NeverSometimesOften1. Has trouble keeping centered on reading.*Symptoms*NeverSometimesOften2. Has difficulty completing tasks or homework on time.Symptoms*NeverSometimesOften3. Skips or repeats lines while reading.Symptoms*NeverSometimesOften4. Loses belongings or things. Symptoms*NeverSometimesOften5. Reading comprehension low, or declines as day wears on.Symptoms*NeverSometimesOften6. Reverses letters, numbers, or confuses similar words.Symptoms*NeverSometimesOften7. Avoids doing near work such as reading.Symptoms*NeverSometimesOften8. First response is "I can't" before trying. Symptoms*NeverSometimesOften9. Is clumsy, accident prone, knocks things over.Symptoms*NeverSometimesOften10. Has forgetful, poor memory. 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 PatientName* First Last Choose a Location*-Select-Nanaimo, BCVictoria, BCPlease 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--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