Binocular Vision Dysfunction - Screening
  • Have you or your child ever experienced a traumatic brain injury (ie: concussion, stroke, etc.) ?

  • BIVSS : Brain Injury Vision Symptom

  • My brain injury was      years ago.

  • How often do the following behaviors occur?

  • Binocular Vision Dysfunction : Screening

  • How often do you or your child experience the following symptoms?

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  • Image field 180

  • Interested in Scheduling an Assessment?

  • Complete the next page to receive a phone call from one of our vision therapy team, and book your appointment today.

  • GENERAL / HEALTH INFORMATION

  • Have you had a routine eye exam within the last 12 months?*
  • Have your symptoms impacted your ability to work or attend school ?*
  • Have your symptoms impacted your ability to perform tasks of daily life ?*
  • Are you currently, or have you recently, participated in rehabilitative therapy for your symptoms ? (ie: physio therapy, speech therapy, occupational therapy)*

  • PATIENT INFORMATION

  • Date of Birth:*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred method of contact:*
  • Should be Empty: