Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Vision Therapy Initial Assessment Form
Patient Name *
Date of Birth
____ / ____ / ________
Primary Vision Concern
Reading Difficulties
Double Vision?
- Yes
- No
- Not sure
Headaches with Near Work?
- Yes
- No
- Not sure
Eye Strain Symptoms
Academic Performance Impact
Previous Eye Exams
Assessor Name
Vision Therapy Initial Assessment Form template from formisoft.com. formisoft.com/intake-templates/vision-therapy-assessment