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Family Vision Care Optometry INC.

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Home
About Us
Contact Us
- Appointment Request
Eyecare Services
Special Testing
New Patient Forms
Returning Patient Update Forms

Home
About Us
Contact Us
- Appointment Request
Eyecare Services
Special Testing
New Patient Forms
Returning Patient Update Forms

Home

>

Returning Patient Update Forms

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Vision Rehabilitation Lifestyle Checklist

Vision Rehabilitation Lifestyle Checklist

First Name*

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Last Name*

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Date: *

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Phone *

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Email *

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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).

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Hours of Operation

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 6:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 6:00 pm

Friday

9:00 am - 6:00 pm

Saturday

Closed

Sunday

Closed

Location

Find Us On The Map!

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Family Vision Care Optometry INC.

Address

28089 Smyth Dr
Valencia, CA 91355

Contact Information (661) 775-1860

(661) 775-9627

[email protected]

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