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Vision and Learning Checklist

Please fill out the following checklist to reflect your child or student’s experiences which will provide our behavioural optometrist with a better understanding of your possible concerns pertaining to your child or student’s visual abilities. Rate the following symptoms or scenarios on a scale of 0-4 as it most suitably applies to the patient.

0 = never

1 = rarely

2 = sometimes

3 = frequently

4 = always

The child or caretaker can fill out the questionnaire. If possible, it is recommended for the child to participate, however having a parent or teacher answer the following questions is also a great option.

Please indicate who is filling out the form (you can check more than one option):

Patient

Parent

Teacher

Other

General Questions

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you have a hard time gauging distance accurately?
Do you avoid reading or work that requires material to be up close?
Do you get headaches from work that is close up?
Do you experience motion sickness?
Do you not enjoy sports or find that you have inconsistent performance when participating in sports?
Do you notice that you have to sit close to the computer to see?

When you are reading:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you skip or repeat lines?
Do you see double or blurry?
Do you feel exhausted?
Do you tilt your head or close an eye?
Do you skip small print when reading?
Do you have difficulty with reading comprehension?
Do you read very close up?
Do you find that it is hard to pay attention when reading?
Do you notice that you need to use your finger or something else to keep your place?
Is it easier if you close one eye?
Do you have better reading comprehension when someone else reads to you?

When you are writing:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you confuse or reverse numbers/ letters?
Do you write on an upward or downward slant?
Do you have a hard time writing down answers and you find it easier to answer orally?

General behavior:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you struggle with time management?
Do you say “I can’t do it” before attempting to do so?
Do you bump into things and knock them over?
Do you tend to lose things?
Do you get frustrated often?
Do one or both of your eyes tend to wander in/ out/ up/ down?

Regarding school:

	never (0)	rarely (1)	sometimes (2)	frequently (3)	always (4)
Do you have a hard time with homework overall?
Is it challenging turning in projects on time?
Do you find it difficult to remember things?
Do you have a hard time looking down at your desk to copy notes from a board?
Do you misnumber rows or columns of numbers?
Do you have a hard time in math class?
Do you benefit from extra help?

20-24 points = suspect for binocular vision problem

> 25 points or more = refer for developmental eye exam

If a child has multiple symptoms or any symptom that occurs always, the child should be assessed by our developmental optometrist. If you are unsure whether the symptoms require a developmental eye exam, please complete this form and our Certified Optometric Vision Therapist will assess the results and contact you with a recommendation of the next steps to take.

Patient First Name

Patient Last Name

Age

Grade

Date

Parent First Name

Parent Last Name

Teacher First Name

Teacher Last Name

Caretaker Occupation

Caretaker First Name

Caretaker Last Name

Phone/Mobile

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School Vision Screenings Give Less Than 4% of a Comprehensive Eye Exam

American Optometric Association

Signs, Symptoms, and Indicators

Although there is no one size fits all way of determining if vision therapy is right for you, the following quiz can give you a good idea as to whether or not you should explore vision therapy.

If you answer more than 5 or more questions with “sometimes, frequently, or always,” we recommend you meet with an optometrist who specializes in vision therapy as soon as possible.

Dr. Ikeda and Dr. Wolff

Dr. Ikeda, FCOVD, is a leading optometrist in the field of neuro optometric rehabilitation and developmental optometry. He has made profound contributions to the field over the years and uses these expertise to provide the highest quality of eye care to his patients. He was Past-President of the Optometric Extension Program Foundation (OEPF) and of the Neuro-Optometric Rehabilitation Association (NORA). He received the “Founding Fathers Medal” for his continued service to NORA and he was recognized as “Physician of the Year” by the Rehabilitation Nurses Society. He is a clinical associate professor of the Western University of Health Sciences College of Optometry and was inducted as a Distinguished Practitioner into the National Academies of Practice (Optometry Academy).

As well as providing primary vision care to patients of all ages, Dr. Wolff performs in Low Vision evaluations. She has spoken at various senior and rehabilitation facilities about Low Vision and enjoys teaching the community about the numerous treatment options that aid people with limited vision.

Dr. Wolff is past President of the Rio Hondo Optometric Society, as well as a member of the American Optometric Association, California Optometric Association, and Neuro-Optometric Rehabilitation Association. She was recognized as “Young Optometrist of the Year” in 2015. Dr. Wolff has also been appointed as Clinical Assistant Professor of the Western University of Health Sciences College of Optometry.

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Testimonials

I haven't actually used the optometrist side, so my review is limited to the vision therapy offered. This office was recommended by my occupational therapist for the treatment of my double vision following a stroke.

Claire A.

Love this location. I had a brain injury accident from day one one. All the team make you feel you still important and hope in the horizon after when the medical system fell you miserably. Dr. Ikeda very professional and very understanding about your issue. Two tombs up.

Jim K.

My husband and I were immediately impressed with Dr Ikeda. I was hit by a car while cycling which caused broken bones and three brain injuries. The brain injuries caused double vision. Dr. Ikeda examined my eyes and got me started on vision therapy with his occupational therapist who specializes in vision therapy. She (Chris) is absolutely great. I am impressed with the array of tools used to help recover my binocular vision. I am doing things I never thought were possible (balance boards etc). Chris pushes me and keeps me motivated. I really enjoy my sessions with her. The office staff is always friendly and they have a wonderful appointment reminder tool that makes it easy to keep my calendar up to date. I am happy the rehab center at Little Co. of Mary recommended them!!

Teresa S.

The Vision Therapy is handled in a separate office through a different door from the shared waiting room. Chris, the vision therapist, has a wide and varied assortment of tools, equipment and resources to best evaluate and treat most vision issues. After just a few visits, my double vision became easier to control, using exercises developed during the therapy process. It was time well-spent.

Joe M.

I have been coming here since I can remember. I love it here. The staff is so amazing and nice. They explain everything they gonna do and never make you feel rushed. Dr. Ikeda has always been my doctor and I would never want another one. He is the doctor for my whole family and is always asking how everyone is doing. I am also so crazy about picking out my frames and have to try so many and each person who helps me take the time and lets me try them all on. I would never want to go anywhere else! I definitely would recommend this office to anyone looking for a great eye doctor.

Kayla W.

This is not for the eye exam but for the frames selection portion. I brought my prescription from Kaiser here with my VSP insurance. The reception staff was very polite and professional. Manny helped me to pick out frames and explain my coverage. Very helpful and patient not like the individual at the other place I rated here on Yelp. I was running late and he still helped me and was not bothered at all. I am so glad I came here ..........very pleased.

Very professional staff and pleasant.