Vision Therapy Vision Assessment Form

Name: EYEcenter Optometric
Address: 2831 J Street, Sacramento, CA, 95816, US
Telephone: 916-442-5126
Price range: $000 - $300

Please answer the following questions about how your eyes feel when reading and doing close work.
Name*
First Last
Phone*
Date*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Email*

	Never	Infrequently (not very often)	Sometimes	Fairly Often	Always
Do you ever feel tired when reading or doing close work?
Do your eyes feel uncomfortable when reading or doing close work?
Do you have headaches when reading or doing close work?
do you feel sleepy when reading or doing close work?
Do you lose concentration when reading or doing close work?
Do you have trouble remembering what you read
Do you have double vision when reading or doing close work?
Do you see the words move, jump, swim, or appear to float on the page when reading or doing close work?
Do you feel like you read slowly?
Do your eyes ever hurt when reading or doing close work?
Do you feel a "pulling feeling" around your eyes when reading or doing close work?
Do you notice the words blurring or coming in and out of focus when reading or doing close work?
Do you lose your place while reading or doing close work?
Do you have to reread the same line of words when reading?

By entering contact information above, I agree to be contacted by EYEcenter Optometric concerning my results.

EYEcenter Optometric