Name: Advanced Eyecare & Therapies
Address: In the Tapio Center, 104 S Freya Street Suite 220, White Flag Bldg, Spokane, WA, 99202, US
Telephone: (509) 213-1144
Price range: $000 - $300

Please note: This questionnaire is for those 14 years old or older.
If you are 13 years old or younger, please click here.

If you would like to tell us more about your symptoms, please write about them in the Comment Section at the end of the Questionnaire. We will combine this information with the responses you gave in the Questionnaire to provide you with a more detailed interpretation of the results. This questionnaire includes 30 questions.

Please Note: We will not sell or otherwise use information on this form except in addressing your inquiry.
(*) indicates a required field.

Directions: For each of the following questions, please check the answer that best describes your situation. If you wear glasses or contact lenses, answer the questions assuming that you are wearing them. Please answer every question.

•Never = Never
•Occasionally = Less than 1 time / week
•Frequently = At least 1 time / week
•Always = Everyday

Symptoms*
Always Frequently Occasionally Never
1. Do you have headaches and / or facial pain?

Symptoms*
Always Frequently Occasionally Never
2. Do you have pain in your eyes with eye movement?

Symptoms*
Always Frequently Occasionally Never
3. Do you experience neck or shoulder discomfort?

Symptoms*
Always Frequently Occasionally Never
4. Do you have dizziness and / or lightheadedness?

Symptoms*
Always Frequently Occasionally Never
5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)?

Symptoms*
Always Frequently Occasionally Never
6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)?

Symptoms*
Always Frequently Occasionally Never
7. Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position?

Symptoms*
Always Frequently Occasionally Never
8. Do you feel unsteady with walking, or drift to one side while walking?

Symptoms*
Always Frequently Occasionally Never
9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)?

Symptoms*
Always Frequently Occasionally Never
10. Do you feel overwhelmed or anxious when in a crowd?

Symptoms*
Always Frequently Occasionally Never
11. Does riding in a car make you feel dizzy or uncomfortable?

Symptoms*
Always Frequently Occasionally Never
12. Do you experience anxiety or nervousness because of your dizziness?

Symptoms*
Always Frequently Occasionally Never
13. Do you ever find yourself with your head tilted to one side?

Symptoms*
Always Frequently Occasionally Never
14. Do you experience poor depth perception or have difficulty estimating distances accurately?

Symptoms*
Always Frequently Occasionally Never
15. Do you experience double / overlapping / shadowed vision at far distances?

Symptoms*
Always Frequently Occasionally Never
16. Do you experience double / overlapping / shadowed vision at near distances?

Symptoms*
Always Frequently Occasionally Never
17. Do you experience glare or have sensitivity to bright lights?

Symptoms*
Always Frequently Occasionally Never
18. Do you close or cover one eye with near or far tasks?

Symptoms*
Always Frequently Occasionally Never
19. Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)?

Symptoms*
Always Frequently Occasionally Never
21. Do you tire easily with close-up tasks (computer work, reading, writing)?

Symptoms*
Always Frequently Occasionally Never
22. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)?

Symptoms*
Always Frequently Occasionally Never
23. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)?

Symptoms*
Always Frequently Occasionally Never
24. Do you blink to clear up distant objects after working at a desk or working with close-up activities (i.e. - computer work, reading, writing)?

Symptoms*
Always Frequently Occasionally Never
25. Do you experience words running together with reading?

Symptoms*
Always Frequently Occasionally Never
26. Do you experience difficulty with reading or reading comprehension?

27. Level of Discomfort*
On an average day, how much are you bothered by the 8 symptoms listed below?
(Rate each symptom from 0 to 10, where 10 is the worst it could be, and where 0 means you have none of that symptom)
0 1 2 3 4 5 6 7 8 9 10
Dizziness
Nausea
Anxiety
Headache
Neckache
Unsteady with Walking
Sensitivity to Light
Reading Difficulty

29. Does the image below bother you?
- Yes
- No

30. Comment Section
If you want to tell us more about you symptoms, or if you have specific questions, record them here:
Please help us help others by using this box to be very specific about how you found us
Please tell us how you found us?*
- Internet Search
- Referred by a friend
- Referred by a professional
- Found us in a forum, blog or social media
Explain:*
Examples include:
If you found us by Internet search, what key words did you use?
If you were referred, who specifically referred you?
If you found out about us on a blog or forum or social media site, specifically which one was it?
Other: Please explain | Heard about us - where?
To help us better serve you, please provide the following information:
Have You Been To The Practice Before?*
- New Patient
- Returning Patient
Name*
First Last
Email*
Best Phone Number*
Back-up Phone Number*
Date of Birth*
MM slash DD slash YYYY
This field is hidden when viewing the form
Your Age
Country*

	Yes	No
Traumatic brain injury or concussion (TBI)?
Reading disability?
Lazy Eye?
Have you ever had an eye operation?

Vision Therapy Quiz for Adults

Vision Therapy Quiz for Adults

Step 1 of 30

Please help us help others by using this box to be very specific about how you found us

To help us better serve you, please provide the following information:

Advanced Eyecare & Therapies

	Always	Frequently	Occasionally	Never
1. Do you have headaches and / or facial pain?

	Always	Frequently	Occasionally	Never
2. Do you have pain in your eyes with eye movement?

	Always	Frequently	Occasionally	Never
3. Do you experience neck or shoulder discomfort?

	Always	Frequently	Occasionally	Never
4. Do you have dizziness and / or lightheadedness?