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Arizona Vision
Therapy Center

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Vision Therapy Progress Check Form

If you have any questions, please call us at 520-886-8800.

Vision Therapy Progress Check Form

First and Last Name*

Current Symptoms

Are you currently experiencing any of the following?

(Please rate severity 0-4, 0 = none, 4 = severe)

Headaches*

0

1

2

3

4

Problems with clairty*

0

1

2

3

4

Double Vision*

0

1

2

3

4

Eye Pain/Strain*

0

1

2

3

4

Eye Fatigue*

0

1

2

3

4

Words Move on Page*

0

1

2

3

4

Motion/Car Sickness*

0

1

2

3

4

Movement Sensitivity*

0

1

2

3

4

Light Sensitivity*

0

1

2

3

4

Nausea*

0

1

2

3

4

Clumsiness*

0

1

2

3

4

Attention Problems*

0

1

2

3

4

Neck Pain*

0

1

2

3

4

Disorientation*

0

1

2

3

4

Dizziness*

0

1

2

3

4

Memory Problems*

0

1

2

3

4

Anxiety/Worry*

0

1

2

3

4

Depression/Despair*

0

1

2

3

4

Anger/Irritability*

0

1

2

3

4

Overwhelm/Emotional*

0

1

2

3

4

Excitement/Joy*

0

1

2

3

4

What has improved since the last progress check

Examples: (reading, writing, attention, coordination, anxiety, etc.)*

What concerns remain that were not in the symptom checklist above?

*

Call and schedule an appointment today!
Phone: 520-886-8800

Fax: 520-886-8805

E-Mail: visiontherapy@live.com

2312 N Rosemont Blvd

#100 & #103

Tucson, AZ 85712

T: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

W: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

Th: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

F: 9:00am-5:00pm (Closed for lunch 1:00pm-2:00pm)

S: 8:00am-2:00pm

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Arizona Vision Therapy Center

Vision Therapy Progress Check Form

Vision Therapy Progress Check Form

Current Symptoms

Are you currently experiencing any of the following?

What has improved since the last progress check

What concerns remain that were not in the symptom checklist above?

Arizona Vision
Therapy Center