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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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Take The Vision Quiz

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

American Optometric Association

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. Zurcher

Originally from Arizona, Levi received his Bachelor’s of Science in Zoology from Northern Arizona University and his Doctorate in Optometry from Pacific University in Oregon. He is board certified in developmental vision and vision therapy by COVD. He purchased the practice from the Inversos in 2012. He likes spending time with his family (wife and two children,) mountain biking, and undertaking creative projects. He wrote the vision therapy software used by the clinic, retinal camera software, and the computerized eye-chart used for exams.

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Testimonials

Such a nice optician. My grandson is only 4 and needs glasses. We were so sad, but he explained the issues, and we will follow up as he suggested.

Anna P.

I had such a good experience with the clinic. Very friendly staff and doctor, did not have to wait for long to be called, and was treated respectfully. Thanks, American Family.

June S.

Dr. Zurcher has gone above and beyond what any other eye doctor has ever done to figure out what is going on with my eyes. Very happy with American Family Vision.

Christine R.

Family Vision Clinic changed our lives! My daughter was frequently car sick, and she was getting headaches every day, often painful enough that they brought her to tears. We saw a string of doctors and therapists, but we made no progress. Finally, we found Dr. Levi Zurcher and his eye therapist Rain. After ten weeks of eye therapy my daughter no longer gets headaches, and she no longer gets car sick. Daily tears are a thing of the past. I really can’t say enough about this clinic. It was fascinating to watch Dr. Zurcher work. For the first time, someone who knew what they were doing was intently studying my daughter, really trying to figure out all of her eye issues, and his therapist Rain is one of the most patient and lovely people that I’ve ever had the good fortune to meet. We’re finished with eye therapy—yay!—and I have switched to American Family Vision Clinic for all of my family’s other eye health needs.

Lars Wulff

Very professional, yet kind and helpful. They do what they can to make the appointment comfortable. I was running a bit late, I made sure ti call. They were able to switch me with a patient who was already there, they treated me with respect, and helped my son have confidence by getting him the eye care he needed that day. Thank you so much! Would recommend to anyone. It's a blessing that they care enough to work with people who have all different types of insurance from work to state coverage.