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Arizona Vision
Therapy Center

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Follow Up Form

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

Follow Up 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/Whiplash*

0

1

2

3

4

Disorientation*

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

Were you able to wear the lenses full time? If not, please explain times worn.

Example: Wore only while driving (about 3 hours/day)*

What did you like best about the current pair of glasses?

*

Was there anything you disliked about the current pair of glasses?

*

Is there anything else you feel the doctor should know?

*

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

Follow Up Form

Follow Up Form

Current Symptoms

Are you currently experiencing any of the following?

Were you able to wear the lenses full time? If not, please explain times worn.

What did you like best about the current pair of glasses?

Was there anything you disliked about the current pair of glasses?

Is there anything else you feel the doctor should know?

Arizona Vision
Therapy Center