Consultation— Survey To schedule a complimentary phone consultation with Dr. Metzger about a learning-related vision problem, please complete the following questionaire. Once we receive your information, we will contact you to set up your private phone consultation with Dr. Metzger. First/Last Name * Phone Number E-mail Address: * Name of Child/Student Grade Age Headaches while or after doing near vision work 0 1 2 3 4 Words appear to run together 0 1 2 3 4 Falls asleep when reading 0 1 2 3 4 Skips or repeats lines while reading 0 1 2 3 4 Head tilts or one eye closed or covered while reading 0 1 2 3 4 Difficulty copying from the chalkboard 0 1 2 3 4 Avoids doing near vision work such as reading 0 1 2 3 4 Omits (drops out) small words while reading 0 1 2 3 4 Reading comprehension low, or declines as day wears on 0 1 2 3 4 Trouble keeping attention on reading 0 1 2 3 4 Poor eye/hand coordination, such as poor handwriting 0 1 2 3 4 Car or motion sick 0 1 2 3 4 Is there another diagnosis to consider during the consultation? AD(H)DAspergersAutismCPCrossed eyeDevelopmental delayDownsLazy eyeOther Best way to contact you to schedule your consult: PhoneE-mail Best time of day for your phone consult: MorningAfternoonEvening Other Comments: * Required

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