Post-VT Survey

Name: Family Eye Care
Address: 3111 U.S. 9, Old Bridge, NJ, 08857, US
Telephone: 732-679-2020
Price range: $000 - $300

Patient's Name:*
Survey Completed By:*
- Parent(s)
- Patient
What was your child's condition prior to vision therapy?
Please give us a general idea of what life was like in school, sports, at home, etc., and what prompted you to seek help at our office.
What was your condition prior to vision therapy?
Please give us a general idea of what life was like with work, hobbies, sports, at home, etc., and what prompted you to seek help at our office.
What steps had you previously taken to get help?
Was your child behind in school? If yes, how far?
Was your child working with a tutor or receiving special services at school? Were they helping?
Please describe.
Was your child classified as learning disabled, ADD/ADHD, or some other label? Was your child on any medication for these? If yes, for how long? Do you feel the medication was helping?
Did you have difficulties when you were in school? Were you ever classified as learning disabled, ADD/ADHD, or some other label? Were you given any medication for these? If yes, for how long? Do you feel the medication was helping?
Prior to your visit to our office, were you having difficulty reading? Working with the computer? Driving? If yes, please describe.
Prior to your visit with our office, was an evaluation done by another eye care professional? If so, what were the findings?
How did you find out about our program?
Since completing Vision Therapy, have you noticed any changes at work, in social situations, or at home? If yes, please describe.
Since completing Vision Therapy, have you noticed any changes in your ability to read, work with the computer, or drive? If yes, please describe.
Have you noticed any other improvements or changes? If yes, please explain.
Since doing Vision Therapy, have you noticed any academic changes? If yes, please describe.
Since doing Vision Therapy, have you noticed any behavioral changes? If yes, please describe.
Has your child's teacher noticed any changes? Can you share some specific comments made?
If your child was classified as learning disabled, ADD/ADHD, or some other label, as there been any change in classification or utilization of school resources since doing vision therapy? Any change in medication?
How did you fit vision therapy into your daily life?
In what ways has your child improved in addition to those noted earlier in this survey?
Additional comments:
Would you be wiling to talk with others considering treatment?*
- Yes
- No
- I will list the best time for people to call me in the box below
- I would prefer to call them rather than having them call me. Please call me with their phone number and I will call them as soon as I can.
Best time for people to call me:

Post-VT Survey

Vision Therapy

Steffani Viveros, OD, FAAO

S. Moshe Roth, OD, FOVDR