SVS - Greensboro Office, 1150 Revolution Mill Dr. Studio 10, Greensboro, NC 27405

Patient Self Assessment

Please submit the form below in order for us to better understand your vision symptoms and needs.

If you prefer, you may print and complete the form and send it to us at the address below.
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*Required Fields
Name:*
 Today's Date:*
E mail:*
 Date of Birth:*
Street Address:*
 Phone:*
City, State, Zip:*
If applicant is a minor, please complete the following:
Responsible Parent Name
 Responsible Parent Home Phone:
Responsible Parent Street Address
 E mail:
Responsible Parent City, State, Zip
0 1 2 3 4 Please assign a value between 0 and 4 for each symptom.
0=Never; 1=Seldom; 2=Occasionally; 3=Frequently; 4=Always
GROUP 1
Avoids or dislikes reading and near work
Avoiding sports or games
Lazy
Behavioral problem
Short attention span
Daydreaming
Saying "I can't" before trying
Becomes easily distracted
GROUP 2
Jerky eye movement or eye turns in/out
Head tilting, closing/ blocking one eye when reading
Rests head on arm when reading
Improper or awkward posture when reading
Frequent loss of place when reading
Loses place when copying
Poor handwriting (up/ downhill, irregular letter/ word spacing, misaligns digits in columns)
Holding reading material too close to the eyes
Inconsistent or poor performance in sports or play
Must use a finger or marker to keep their place when reading
Difficulty with tools, scissors, calculator, keys
Tendency to knock things over on desk or table
Moves head while reading
Clumsy, bumps into things
Fidgety when reading or writing
GROUP 3
Confuses similar looking words
Failure to recognize the same word in the next sentence
Poor or declining reading comprehension as reading continues
Fails to visualize (can't describe what they have been reading)
Reads too slowly
Says words aloud or moves lips while reading
Has no voice inflection when reading
GROUP 4/5
Complains of letters, words, or lines running together or jumping around
Omits, inserts, or rereads letters/words/phrases,
Reverses letters (p,d,b,q) or words (saw, was) after first grade
Inability to estimate distance accurately
Difficulty with money concepts, making change
Misplaces or loses papers, objects, belongings
Repeatedly confuses right and left
Difficulty completing assignments in reasonable time
Difficulty with time management
Forgetful, poor memory
Slow reaction time and poor timing in sports or play
GROUP 6/7
Eyes are red, sore, burning, stinging, tearing or itching after doing near work
Car sickness/ motion sickness
Falling asleep or drowsiness when reading
Blurred or double vision while reading or writing
Vision worse at the end of the day
Headaches, dizziness or nausea after reading or near work
GROUP 8
Squints, frowns, scowls, rubs/blinks eyes, after short periods of near work
Dyslexic
Attention Deficit Disorder (ADD)
Slow learner
Juvenile delinquency
Working below potential
Learning Disabled (LD)
Smart in everything but school
Low self-esteem
Has emotional outbursts
Fatigue, frustration, stress, restlessness after maintaining visual concentration
Irritability
Gradually decreasing grades

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SVS - Greensboro Office
1150 Revolution Mill Drive
Studio 10
Greensboro, NC 27405
336-460-0752

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