Pri Vision Update Form printable pdf download

PRI Vision Update Form

Date:____________________

Patient Name:____________________________________

Referring

Therapist:__________________________________Phone:___________________________

Email:__________________________________________

Areas where progress has been good:

______________________________________________________________________________

Areas where progress has been slow:

______________________________________________________________________________

Has the patient been neutral the last time seen by you? Yes / No

If yes, under what conditions?

_______ With PRI Program Eyewear alone

_______ Without PRI Program Eyewear

_______ With mouth appliance alone

_______ With Program Eyewear plus mouth appliance

_______ Other_________________________________

If no, have they ever been neutral with the Program Eyewear? _______________________

Which activities has the patient mastered? (Phase/Act #)

______________________________________________________________________________

Which activities hasn’t the patient mastered?

______________________________________________________________________________

Are there circumstances/activities that seem to contribute to the patient’s symptoms increasing?

For example, being at the computer at work makes things worse, but weekends are better. Please

be as specific as possible:

______________________________________________________________________________

Pri Vision Update Form