Vision Therapy Initial Assessment Form

This vision therapy assessment form provides a comprehensive evaluation framework for optometrists specializing in functional vision care and visual rehabilitation. It captures detailed information about eye coordination difficulties, focusing problems, double vision, eye strain, headaches related to visual tasks, and reading or learning challenges. The form includes assessment of visual processing skills, tracking abilities, depth perception issues, and symptoms during near work or computer use.

Ideal for behavioral optometry practices, pediatric eye care specialists, occupational therapy clinics with vision programs, and school-based vision services, this template helps identify candidates for vision therapy intervention. It documents baseline visual function to support treatment planning for conditions like convergence insufficiency, amblyopia management, post-concussion vision syndrome, and learning-related vision problems. The structured format facilitates insurance pre-authorization and tracks patient progress throughout therapy.