Vision Therapy Screening

About you

Filling this in for a child? Enter the child's name and date of birth and your own phone or email.

Who is this for?

Myself My child

First name *

Last name *

Date of birth

Phone *

Email *

Phone or email is enough; both help us find your file.

Are your glasses (if any) up to date?

Last eye test

Concussion or head injury in the last 12 months?

Hours a day on screens or close work

Any history of seizures or epilepsy?

What would you like to be easier? (optional)

Think about reading, homework, screens and other close work over the last week. Answer every question.

How much has each of these bothered you in the last week?

Questions? Call Fantastic Glasses at (587) 997-3937.