Vision Therapy Intake Form

Vision Therapy Intake Form — Form Fields

This healthcare template includes 9 fields. Collect history and symptoms for patients referred to vision therapy for binocular vision or visual processing conditions. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Parent or Contact Email (email, required)
• Phone Number (text, required)
• Referring Eye Doctor (text, optional)
• Presenting Symptoms or Concerns (checkboxes, required) — options: Double vision, Headaches with reading, Eye strain, Losing place while reading, Words moving on page, Difficulty concentrating, Poor depth perception, Eye turn (strabismus), Other
• Has patient had previous eye muscle surgery? (multiple choice, required) — options: Yes, No
• Age of first concern (multiple choice, optional) — options: Birth to 2, 3-5 years, 6-10 years, 11-18 years, Adult onset
• Additional history or concerns (long text, optional)