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Vision and Learning Checklist

Please fill out the following checklist to reflect your child or student’s experiences which will provide our behavioural optometrist with a better understanding of your possible concerns pertaining to your child or student’s visual abilities. Rate the following symptoms or scenarios on a scale of 0-4 as it most suitably applies to the patient.

0 = never

1 = rarely

2 = sometimes

3 = frequently

4 = always

The child or caretaker can fill out the questionnaire. If possible, it is recommended for the child to participate, however having a parent or teacher answer the following questions is also a great option.

Please indicate who is filling out the form (you can check more than one option):

Patient

Parent

Teacher

Other

General Questions

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you have a hard time gauging distance accurately?
Do you avoid reading or work that requires material to be up close?
Do you get headaches from work that is close up?
Do you experience motion sickness?
Do you not enjoy sports or find that you have inconsistent performance when participating in sports?
Do you notice that you have to sit close to the computer to see?

When you are reading:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you skip or repeat lines?
Do you see double or blurry?
Do you feel exhausted?
Do you tilt your head or close an eye?
Do you skip small print when reading?
Do you have difficulty with reading comprehension?
Do you read very close up?
Do you find that it is hard to pay attention when reading?
Do you notice that you need to use your finger or something else to keep your place?
Is it easier if you close one eye?
Do you have better reading comprehension when someone else reads to you?

When you are writing:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you confuse or reverse numbers/ letters?
Do you write on an upward or downward slant?
Do you have a hard time writing down answers and you find it easier to answer orally?

General behavior:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you struggle with time management?
Do you say “I can’t do it” before attempting to do so?
Do you bump into things and knock them over?
Do you tend to lose things?
Do you get frustrated often?
Do one or both of your eyes tend to wander in/ out/ up/ down?

Regarding school:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you have a hard time with homework overall?
Is it challenging turning in projects on time?
Do you find it difficult to remember things?
Do you have a hard time looking down at your desk to copy notes from a board?
Do you misnumber rows or columns of numbers?
Do you have a hard time in math class?
Do you benefit from extra help?

20-24 points = suspect for binocular vision problem

> 25 points or more = refer for developmental eye exam

If a child has multiple symptoms or any symptom that occurs always, the child should be assessed by our developmental optometrist. If you are unsure whether the symptoms require a developmental eye exam, please complete this form and our Certified Optometric Vision Therapist will assess the results and contact you with a recommendation of the next steps to take.

Patient First Name

Patient Last Name

Age

Grade

Date

Parent First Name

Parent Last Name

Teacher First Name

Teacher Last Name

Caretaker Occupation

Caretaker First Name

Caretaker Last Name

Phone/Mobile

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School Vision Screenings Give Less Than 4% of a Comprehensive Eye Exam

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Signs, Symptoms, and Indicators

Although there is no one size fits all way of determining if vision therapy is right for you, the following quiz can give you a good idea as to whether or not you should explore vision therapy.

If you answer more than 5 or more questions with “sometimes, frequently, or always,” we recommend you meet with an optometrist who specializes in vision therapy as soon as possible.

Dr. McBryar

Dr. Heather McBryar is a certified optometrist and a Tennessee native. As a pediatric optometrist with more than 16 years' experience, she is considered a leading voice in her field. Her fascination with the field began at a young age with a visit to the eye doctor for a minor vision issue of her own, and later upon learning about a vision condition that ran in her family. Dr. McBryar's son, who has a vision problem and is also on the autism spectrum, has motivated her to help children of all stages of development succeed at school and in life.

Dr. McBryar graduated with honors from Nova Southeastern University College of Optometry. She is a Fellow of the College of Optometrists in Vision Development (COVD), a candidate for Fellowship in the Neuro-Optometric Rehabilitation Association (NORA), and a Diplomate of the American Board of Optometry (ABO).

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Testimonials

Vision therapy is well worth the response, time and effort. Our Son had a hard time focusing and writing neatly. After vision therapy Seth could complete a task in half the time if previously took. His abilities to focus improved greatly and so did his handwriting.

Also, he was better at listening. As a parent, we wanted learning to be fun for our Son, and vision therapy made this possible.

Amanda T.

Vision Therapy is well worth the expense, time and effort. Our son had a hard time focusing handwriting neatly. After vision therapy Seth could complete a task in half the time it previously took his abilities to focus and improved greatly and so did his handwriting.

Also, he was better at listening. As a parent you wanted learning to be fun for our son and vision therapy made this possible.

Alexa H.

Vision Therapy has given or son the tools he needs to be able to scan and read the written word more effectively and efficiently.

He love working with John and these working sessions give him the motivation to gladly work on his homework assignments.

It amazed us to see the difference in the tracking of his eyes and along a line of it's from the beginning to the end of the treatment.

Dr. McBryar , Kristen and John are all marvelous and we would recommend them to anyone I only wish that we would have found them sooner!

Charlotte M.

Prior to coming to the institute for vision development my son complained of daily headaches. Therapy has eliminated his headaches completely. I love knowing my son is able to learn pain-free for the rest of his life because of the work that has been done over just a few weeks in this office. He he absolutely loved coming that didn't even feel like going to a doctor or therapy. We are grateful for the relief he was able to find by coming here.

Thank you!

Olivia C.

Seems much less frustrated with life

Reads non-stop and fast

Spelling abilities have been hugely improved

Seems much more confident

Thank You!!!

Kelly O.

When we first came to the practice, my son did not have huge issues, but lots of small ones- trouble with reading, sports (hitting the baseball consistently), coordination, etc- that were not easily detectable,but when put together presented issues. The staff here were all very professional and loving towards him. While I was concerned in the reading, my son was concerned with the athletic side. Seeing improvement night off the bat gave him confidence that i have nor seen in him and made him want to not only Come to therapy, but also made him want to work hard. He has surpassed his grade level and above in reading and hit his first home run this year! Thank you!!!