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Home » Contact Us » Vision Therapy Vision Assessment Form

Vision Therapy Vision Assessment Form

Vision Therapy Assessment Form

  • Please answer the following questions about how your eyes feel when reading and doing close work.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • NeverInfrequently (not very often)SometimesFairly OftenAlways
    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.

Call Our Offices

Dear Patients:

Starting Tuesday, June 2, all five EYEcenter locations will be open for routine eye health and vision needs based upon recommendations from our professional organizations, the Center for Disease Control (CDC), and directives from Governor Newsom’s office.

Your doctors and staff at EYEcenter will continue to provide you with the state of the art, advanced eye care services that you are used to. What will be different as part of our “new normal” will be policies, procedures, and safeguards intended to ensure the health and well being of our patients, doctors, and staff.

Click below for more information and updated clinic hours.

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