1. Do you have headaches and / or facial pain? | | | | |
2. Do you have pain in your eyes with eye movement? | | | | |
3. Do you experience neck or shoulder discomfort? | | | | |
4. Do you have dizziness and / or lightheadedness? | | | | |
5. Do you experience dizziness, light-headedness, or nausea while performing close-up activities (i.e. - computer work, reading, writing)? | | | | |
6. Do you experience dizziness, light-headedness, or nausea while performing far-distance activities (i.e. - driving, television, movies)? | | | | |
7. Do you experience dizziness, light-headedness, or nausea when bending down and standing back up, or when getting up quickly from a seated position? | | | | |
8. Do you feel unsteady with walking, or drift to one side while walking? | | | | |
9. Do you feel overwhelmed or anxious while walking in a large department store (i.e. – Target, Wal-Mart, etc.)? | | | | |
10. Do you feel overwhelmed or anxious when in a crowd? | | | | |
11. Does riding in a car make you feel dizzy or uncomfortable? | | | | |
12. Do you experience anxiety or nervousness because of your dizziness? | | | | |
13. Do you ever find yourself with your head tilted to one side? | | | | |
14. Do you experience poor depth perception or have difficulty estimating distances accurately? | | | | |
15. Do you experience double / overlapping / shadowed vision at far distances? | | | | |
16. Do you experience double / overlapping / shadowed vision at near distances? | | | | |
17. Do you experience glare or have sensitivity to bright lights? | | | | |
18. Do you close or cover one eye with near or far tasks? | | | | |
19. Do you skip lines or lose your place while reading (do you use your finger or a ruler or other guides to maintain your position on the page)? | | | | |
20. Do you tire easily with close-up tasks (computer work, reading, writing)? | | | | |
21. Do you experience blurred vision with far-distance activities (i.e. - driving, television, movies, chalkboard at school)? | | | | |
22. Do you experience blurred vision with close-up activities (i.e. - computer work, reading, writing)? | | | | |
23. Do you blink to clear up distant objects after working at a desk or working with close-up activities (i.e. - computer work, reading, writing)? | | | | |
24. Do you experience words running together with reading? | | | | |
25. Do you experience difficulty with reading or reading comprehension? | | | | |
Appointment times may vary so call us for available.