Sophie Rose Optometry

Vision Therapy Questionnaire

This questionnaire will allow me to plan for your appointment

Adult Questionnaire

This questionnaire will allow me to plan for your appointment, and give me as much background information as possible. PLEASE complete this form before the appointment.

About You

Reason for referral


Yes No
If yes please give more details and send copy of report to read before appointment.

History


If yes, and you have a copy of the prescription, please bring it to your appointment.
Yes No


Yes No


Yes No


Yes No


Left Handed Right Handed Ambidextrous

Visual Symptoms Checklist

Please indicate below the frequency of your symptoms.

Reading:

  Occasionally Frequently

Please tick whichever of the following apply:

Frowning
Blinking
Squinting
Other facial expressions

Visual Symptoms Checklist

Please indicate below the frequency of your symptoms.

Body posture and Space Awareness:

  Occasionally Frequently

Visual Symptoms Checklist

Please indicate below the frequency of your symptoms.

General Behaviour:

  Occasionally Frequently

Visual Symptoms Checklist

Please indicate below the frequency of your symptoms.

Writing and Other Desk Tasks:

  Occasionally Frequently

Any further comments:

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T: 01256 862443 E: sophie@sophieroseoptometry.co.uk