VISION QUIZ
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please use the following to rate the statements below:
0 = Never 1= Rarely 2= Sometimes 3= Frequently 4= Always
Rows
0
1
2
3
4
Frequent feelings of nervousness or anxiety in busy environments
Nausea or dizziness when reading or using the computer
Fears or phobias of spaces (either too open or too enclosed)
Headaches or stomach pain when worried
Easily startled by things jumping into view suddenly
Trouble with Circadian rhythm (sleep schedule is off or inconsistent)
Feeling slowed down in thinking, speaking, or reading
Difficulty expressing thoughts well (finding the right word or making inappropriate word substitutions)
Difficulty concentrating, sitting still, and/or remembering things recently learned
Upset when things are out of place
Problems with change or when things do not go as planned
Difficulty seeing options and making solid decisions
Problems paying attention to tasks or events that are not exciting
Becomes easily frustrated when working with others
Becomes spacey or confused easily
Visual or auditory problems like seeing shadows or hearing music/voices not perceived by others
Difficulty reading (words move on page, reads slowly, says incorrect words, avoids) Needs extra time on assignments and tests
Problems with poor judgment (risk taking or overly shy)
Easily overwhelmed by basic daily activities
Loses things easily
Disorganized
Easily distracted
Poor planning skills
Problems starting or finishing projects
Bumps or trips into things frequently
TOTAL ANSWER
Would you like our office to contact you to schedule an appointment?
*
Yes
No
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