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VT ACHIEVEMENT REPORT

At this point in our therapy program we want to see what changes you, your parents, teachers or others have noticed in the following areas.
Name(Required)
MM slash DD slash YYYY

IMPROVEMENTS

Please check all areas where improvements have been noted.
READING
EMOTIONAL & BEHAVIORAL CHANGES
ACADEMIC CHANGES
OCULAR SYMPTOMS
CHANGES IN LOCALIZATION & NAVIGATION
PATIENT’S GOALS

PARENT’S GOALS


Please include any other comments relative to your vision therapy program on the back
I understand that the doctor will discuss the exam findings during the progress evaluation, however if you would like written documentation the following options are available:
Request for Additional Vision Therapy Re-Evaluation (VTR) Services
Patient’s Name(Required)
MM slash DD slash YYYY