Vision Therapy Survey Vision Therapy Survey Are you curious about whether or not you might need vision therapy? Please take the following quick survey which will evaluate whether you might need a referral for a vision therapy consultation. 1. Do your eyes feel tired when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 2. Do your eyes feel uncomfortable when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 3. Do you have headaches when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 4. Do you feel sleepy when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 5. Do you lose concentration when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 6. Do you have trouble remembering what you have read? Never (not often) Infrequently Sometimes Fairly Often Always 7. Do you have double vision when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 9. Do you feel like you read slowly? Never (not often) Infrequently Sometimes Fairly Often Always 10. Do your eyes ever hurt when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 11. Do you feel a "pulling" feeling around your eyes when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 12. Do you notice the words blurring or coming in and out of focus when reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 13. Do you lose your place while reading or doing close work? Never (not often) Infrequently Sometimes Fairly Often Always 14. Do you have to re-read the same line of words when reading? Never (not often) Infrequently Sometimes Fairly Often Always
