• Date Format: MM slash DD slash YYYY
  • Please rate the following signs and symptoms according to your current observations and/or your patient's current reports about how his/her eyes feel. Indicate the frequency of these signs and symptoms using the following number scale:
    Score 0 for Never, 1 for Infrequently, 2 for Sometimes, 3 for Fairly Often, 4 for Always

    Legend: N= Never , I= Infrequently , S= Sometimes , FO= Fairly Often , A= Always
  • **Total scores greater than or equal to 16 warrant a consultation with a Developmental Optometrist specializing in Neuro-optometric Rehabilitation.
  • This field is for validation purposes and should be left unchanged.