Online Forms

Due to COVID-19 our office is open by appointment only. When you arrive at the office please stay in your vehicle and call 306-585-2424 to check-in. We will review your information over the phone and will let you know when we are ready to welcome you into the office. If you have a mask we would appreciate you wearing it, however it is not mandatory. Thanks for your cooperation!

Home Forms Vision Therapy - Pre-Screen

Vision Therapy - Pre-Screen

Our online Vision Therapy pre-screen can give you an impression of your current eye health based on symptoms you may currently have. Once you complete the screen, you'll be given your score and shown where you fall in the scales. This is only a screening tool and will not pick up all cases where Vision Therapy would be beneficial. The best way to know for sure is through a full assessment.

Patient Name

Email Address

Phone Number

	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Blurred vision at near	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Double Vision	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Headaches associated with near work	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Words move or run together when reading	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Falling asleep or get tired when reading	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Vision worse at the end of the day	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Skipping or repeating lines when reading	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Head tilt, covering or closing one eye when reading	Never/Non-existent	Seldom	Occasionally	Frequently	Always
	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Difficulty copying from the chalkboard	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Avoidance of reading and near work	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Omitting small words when reading	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Writing uphill or downhill	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Difficulty with reading comprehension	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Inconsistent/poor sports performance	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Holding reading material too close	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Short attention span	Never/Non-existent	Seldom	Occasionally	Frequently	Always
	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Difficulty completing assignments in reasonable time	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Saying "I can't" before trying	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Avoiding sports and games	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Difficulty with hand tools-Scissors, calculator, keys, etc	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Inability to estimate distance accurately	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Tendency to knock things over on desk or table	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Difficulty with time management	Never/Non-existent	Seldom	Occasionally	Frequently	Always
Car sickness/motion sickness	Never/Non-existent	Seldom	Occasionally	Frequently	Always
	Never/Non-existent	Seldom	Occasionally	Frequently	Always