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

Patient Profile

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
Blurred vision at near
Double Vision
Headaches associated with near work
Words run together when reading
Burning, stinging, watery eyes
Falling asleep when reading
Vision worse at the end of the day
Dizziness or nausea associated with near work
Car sickness/motion sickness
Skipping or repeating lines when reading
Head tilt or closing one eye when reading
Difficulty copying from the chalkboard
Avoidance of reading and near work
Omitting small words when reading
Writing uphill or downhill
Misaligning digits in columns of numbers
Reading comprehension declining over time
Holding reading material too close
Difficulty with tools, scissors. calculator, keys
Inability to estimate distance accurately
Tendency to knock things over on desk or table
Inconsistent/poor sports performance
Difficulty completing assignment in reasonable time
Avoiding sports and games
Difficulty with time management
Difficulty with money concepts, making change
Short attention span
Saying "I can't" before trying
Misplaces or loses papers, objects, belongings
Forgetful, poor memory

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