320 W River Park Dr Ste 245, Provo, UT 84604

Schedule an Appointment | (801) 800-8508

320 W River Park Dr Ste 245, Provo, UT 84604

Schedule an Appointment | (801) 800-8508

Visual Symptom Assessment

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Brain Injury?
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Are you under or over 18 years old?
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Answer below if you are under 18 years old

Vision blurs when reading, writing, or working on computer
Headaches when reading, writing, or working on computer
Words go double or appear to move around when reading
Burning, itching or watery eyes when reading
Loses place when reading
Tilts head or closes/covers one eye when reading
Difficulty copying from the whiteboard/chalkboard
Avoids near work such as reading or writing
Skips over or leaves out small words when reading
Writes uphill or downhill; difficulty writing in a straight line
Difficulty lining up numbers when doing math
Difficulty understanding what you read / poor comprehension
Holds books too close; leans too close to computer screen
Difficulty keeping attention on reading material
Difficulty finishing assignments on time
First response is "I can't" before trying
Clumsy, bumps into things, knocks things over
Does not use time well when doing near work (homework)
Loses belongings and things
Forgetful, poor memory

Answer below if you are over 18 years old

Eyesight Clarity

Clarity of vision changes or fluctuates during the day

Visual Comfort

Eye discomfort / sore eyes / eyestrain
Feel "pulling" around the eyes
Headaches or dizziness after using eyes
Eye fatigue / very tired after using eyes all day

Doubling

Print moves in and out of focus when reading

Light Sensitivity

Normal indoor lighting is uncomfortable – too much glare
Indoors fluorescent lighting is bothersome or annoying

Depth Perception

Clumsiness / misjudge where objects really are
Lack of confidence walking / missing steps / stumbling

Peripheral Vision

Side vision distorted / objects move or change position
What looks straight ahead--isn’t always straight ahead
Avoid crowds / can’t tolerate “visually-busy” places

Reading

Short attention span / easily distracted when reading
Difficulty / slowness with reading and writing
Poor reading comprehension / can’t remember what was read
Confusion of words / skip words during reading
Lose place / have to use finger not to lose place when reading

Please do not submit any Protected Health Information (PHI).

CONTACT US

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Please do not submit any Protected Health Information (PHI).