tnvisiontherapy.com - Retention Check Forms

Date

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

It has been several months or years since your last visit in this office. It is important that you inform our office of any new injuries, symptoms, surgeries or diseases that are significant since your last visit.

If you/your child are currently being seen by any of the following providers, please complete all information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

Date

Rows	Never (0)	Seldom (1)	Occasional (2)	Frequently (3)	Always (4)
Blur when looking at near
Double vision, doubled or overlapping words on page
Headaches while or after doing near vision work
Words appear to run together when reading
Burning, itching or watery eyes
Falls asleep when reading
Seeing and visual work is worse at the end of the day
Skips or repeats lines while reading
Dizziness or nausea when doing near work
Head tilts or one eye is closed or covered while reading
Difficulty copying from the chalkboard
Avoids doing near vision work such as reading
Omits (drops out) small words while reading
Writes up or down hill
Misaligns digits or columns of numbers
Reading comprehension low, or declines as day wears on
Poor, inconsistent performance in sports
Holds books too close, leans too close to computer screen
Trouble keeping attention centered on reading
Difficulty completing assignments on time
First response is “I can’t” before trying
Avoids sports and games
Poor hand/eye coordination, such as poor handwriting
Does not judge distances accurately
Clumsy, accident prone, knocks things over
Does not use or plan his/her time well
Does not count or make change well
Loses belongings and things
Car or motion sickness
Forgetful, poor memory

TENNESSEE VISION THERAPY

TENNESSEE VISION THERAPY COVD Lifestyle Checklist