Oklahoma Vision Development Center

Patient Assessment
For the Med iLight

Please complete these fields so we can accurately decide what Med iLight sequence if any will be most beneficial to you or your child

check any that apply	Autism Double Vision Experienced a Brain Injury Have an anxiety disorder Depression Eye Turn
	Headaches after doing near work
	confuses right and left
	Tired after doing a visual task
	Homework takes longer than normal
	Slow reader Poor reading comprehension
Last Eye Exam:
First Name:
Last Name:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Email
Comments:	Enter comments here!

Oklahoma Vision Development Center
4520 S. Harvard Ave.
Tulsa, Ok 74135
(918) 633-9085
FAX (918) 392-7006