(661) 775-1860

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(661) 775-1860

Home Returning Patient Update Forms Vision Rehabilitation Lifestyle Checklist

Vision Rehabilitation Lifestyle Checklist

First Name

Last Name

Date:

Phone

Please assign a value between 0 and 4 for each symptom. 0 is Never or Non-existent, 1 is Occasionally (1-2 times per month), 2 is Often (1-2 times every two weeks), 3 is Frequently (3-5 times per week), 4 is Always Happens. Also check off if the symptom existed prior to your injury/accident.

Double vision at distance 01 2 3 4 Existed prior to injury

Double Vision at near 0 1 2 3 4 Existed prior to injury

Blurred vision at near 0 1 2 3 4 Existed prior to injury

Closes or covers one eye 0 1 2 3 4 Existed prior to injury

Sensitive to sunlight 0 1 2 3 4 Existed prior to injury

Sensitive to fluorescent lights 0 1 2 3 4 Existed prior to injury

Has difficulty seeing in dim illumination 0 1 2 3 4 Existed prior to injury

Difficulty changing focus from far to near 0 1 2 3 4 Existed prior to injury

Head tilted to one side 0 1 2 3 4 Existed prior to injury

Burning or stinging eyes 0 1 2 3 4 Existed prior to injury

Itchy eyes 0 1 2 3 4 Existed prior to injury

Headaches associated with near work 0 1 2 3 4 Existed prior to injury

Skipping or repeating lines when reading 0 1 2 3 4 Existed prior to injury

Words running together when reading 0 1 2 3 4 Existed prior to injury

Omitting small words when reading 0 1 2 3 4 Existed prior to injury

Reading comprehension declining over time 0 1 2 3 4 Existed prior to injury

Avoidance of reading at near work 0 1 2 3 4 Existed prior to injury

Difficulty with writing; writing uphill or downhill 0 1 2 3 4 Existed prior to injury

Hold reading material too close 0 1 2 3 4 Existed prior to injury

Falling asleep when reading 0 1 2 3 4 Existed prior to injury

Confusion/Disorientation 0 1 2 3 4 Existed prior to injury

Dizziness or nausea 0 1 2 3 4 Existed prior to injury

Car sickness/Motion sickness 0 1 2 3 4 Existed prior to injury

Movement of objects in environment is bothersome 0 1 2 3 4 Existed prior to injury

Patterned wallpaper or carpets are bothersome 0 1 2 3 4 Existed prior to injury

Object jumps in and out of field of view 0 1 2 3 4 Existed prior to injury

Difficulty with peripheral vision 0 1 2 3 4 Existed prior to injury

Poor balance 0 1 2 3 4 Existed prior to injury

Floor looks tilted 0 1 2 3 4 Existed prior to injury

Uncomfortable in a market or mall 0 1 2 3 4 Existed prior to injury

Disoriented with head movements 0 1 2 3 4 Existed prior to injury

Flashes of light 0 1 2 3 4 Existed prior to injury

Dislikes heights 0 1 2 3 4 Existed prior to injury

Bumps into things 0 1 2 3 4 Existed prior to injury

Difficulty using both sides of the body together 0 1 2 3 4 Existed prior to injury

Tendency to knock things over on a desk or table 0 1 2 3 4 Existed prior to injury

Difficulty with dressing 0 1 2 3 4 Existed prior to injury

Difficulty with bathing/personal hygiene 0 1 2 3 4 Existed prior to injury

Difficulty with hand tools. Ex. scissors, screwdrivers, calculators, keys 0 1 2 3 4 Existed prior to injury

Poor hand-eye coordination 0 1 2 3 4 Existed prior to injury

Inability to estimate distance accurately 0 1 2 3 4 Existed prior to injury

Misplaces or loses papers, objects or belongings 0 1 2 3 4 Existed prior to injury

Difficulty following a series of directions 0 1 2 3 4 Existed prior to injury

Forgetful or poor memory 0 1 2 3 4 Existed prior to injury

Difficulty with time management 0 1 2 3 4 Existed prior to injury

Difficulty with money concepts, making change 0 1 2 3 4 Existed prior to injury

Difficulty performing tasks formerly easy or routine 0 1 2 3 4 Existed prior to injury

Short attention span 0 1 2 3 4 Existed prior to injury

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

Location

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Family Vision Care Optometry INC.

Contact Information

Phone: (661) 775-1860

Fax: (661) 775-9627

Email: customercare@fvcoptometry.net

Address

28089 Smyth Dr
Valencia, CA 91355

Hours of Operation

Monday

09:00 am - 06:00 pm

Tuesday

09:00 am - 06:00 pm

Wednesday

09:00 am - 06:00 pm

Thursday

09:00 am - 06:00 pm

Friday

09:00 am - 06:00 pm

Saturday

Closed

Sunday

Closed

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