Binocular Vision History

Binocular Vision History

Airdrie Family Eye Doctors
General Information
Patient Name*

First NameLast Name
Parent/Legal Guardian Name (1)

First NameLast Name
Parent/Legal Guardian Name (2)

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Why are you looking into Vision Therapy?*
Who referred you or encouraged you to look into vision therapy? (leave blank if self-referral)
If you* have been diagnosed with any cognitive impairments, dyslexia, ADHD, giftedness, or other, please list them here. (*the person for whom the appointment was booked)
Do you currently see an ophthalmologist? If so, who?

Next is a section that will allow us to better understand your (or your child's) vision and visual symptoms prior to your appointment. Please answer to the best of your ability.

If you are completing this form on behalf of your child, we encourage you to go through this questionnaire with them. Note any questions where your answer differs from your childs - we will discuss them at your appointment.

These questions use a 0-4 scale, where 0 is never and 4 is always. If the question does not apply for any reason, please answer 0.

General Information