Clone of Vision Pilot Submission Form

Vision Pilot Submission Form (Month - 6)

Thank you for participating in the Mirsonics Vision Pilot Study. Please submit your results using this form after completing your monthly vision test.
Before you begin:
Make sure you’ve followed the testing guidelines exactly as described in the instruction sheet.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter your phone number in this format: 678-678-3235Format: (000) 000-0000.
Steps to Complete and Submit:

***Print and Prepare your vision chart on A4 or 8.5"×11" paper at 100% scale (do not “fit to page”).

Please take this test without wearing glasses or contact lenses.

Test your Right Eye (cover left).
Test your Left Eye (cover right).
Test with Both Eyes open.

For each line on the chart, write down the letters you can read in your Vision Log table.
After finishing, compare your answers while wearing glasses and record how many letters were correct.

Fill in your Vision Log Table completely for this month (Right Eye, Left Eye, Both Eyes).
Once done, sign, and submit the form.
Questions About Your Test Environment

Please answer these questions to help us better interpret your vision test results.
How would you describe the lighting in your room during this test?
How were your eyes feeling during this test?
Date

MonthDayYear
Hour MinutesAM/PM Option
Do you currently wear glasses or contact lenses?
Month - 6 Right Eye Test

M6-R
1st Line
Please enter only the number of letters you read correctly for this line. Example: Type 4 if you read 4 out of 5 letters correctly. Do not type “4/5” or “five out of five” — only enter the number itself (1, 2, 3, 4, or 5).
2nd Line
3rd Line
4th Line
5th Line
6th Line
7th Line
8th Line
9th Line
10th Line
11th Line
Calculation M6-R
Month - 6 Left Eye Test

M6-L
1st Line
Please enter only the number of letters you read correctly for this line. Example: Type 4 if you read 4 out of 5 letters correctly. Do not type “4/5” or “five out of five” — only enter the number itself (1, 2, 3, 4, or 5).
2nd Line
3rd Line
4th Line
5th Line
6th Line
7th Line
8th Line
9th Line
10th Line
11th Line
Calculation M6-L
Month - 6 Both Eyes Test

M6-B
1st Line
Please enter only the number of letters you read correctly for this line. Example: Type 4 if you read 4 out of 5 letters correctly. Do not type “4/5” or “five out of five” — only enter the number itself (1, 2, 3, 4, or 5).
2nd Line
3rd Line
4th Line
5th Line
6th Line
7th Line
8th Line
9th Line
10th Line
11th Line
Calculation M6-B
To help us better understand your progress, which audio did you primarily listen to last month?
What shifts or insights have you noticed since beginning the program?
Feel free to share any physical changes, emotional shifts, or daily experiences you've noticed, even small details can be important.
(Optional) Upload a short video, audio, or note sharing how you’ve been feeling. Your experience helps us improve.

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Vision Pilot Submission Form (Month - 6)

Questions About Your Test Environment

Month - 6 Right Eye Test

Month - 6 Left Eye Test

Month - 6 Both Eyes Test