Vision Therapy Intake Form
What a vision therapy intake form asks the parent, with sample questions on development, school, reading symptoms, and family history.
A vision therapy intake form records why a child is being tested, development, eye history, school, symptoms, and family history before a binocular vision evaluation. The sample questions on this page are built from a neuro-optometry practice's pediatric history form and an American Optometric Association guideline.
Vision therapy intake form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a vision therapy intake form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample vision therapy intake form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- What brings your child in for testing?Visit goals
- What do you hope the testing will show?Visit goals
- Were there problems during pregnancy or delivery?Development
- Did your child reach early milestones on time?Development
- Has your child had patching or vision therapy before?Eye history
- Did your child need glasses at a young age?Eye history
- What grade is your child in?School
- Does your child have a 504 plan or IEP?School
- Does print blur or double when your child reads?Symptoms
- How long can your child read comfortably?Symptoms
- Has a family member had vision therapy?Family history
- Does anyone in the family have learning disorders?Family history
These are examples to read, not a form to fill in.
Vision therapy intake form: FAQ
What does a vision therapy intake form ask?
The sample questions on this page are based on a neuro-optometry practice's pediatric history form and an American Optometric Association clinical practice guideline. This page groups them into six areas: visit goals, development, eye history, school, symptoms, and family history.
Who fills in a vision therapy intake form?
A parent or guardian answers for the child before the first testing visit. The pediatric history form starts with the main visual concerns and who referred the child.
Does it ask about school support?
Yes. The pediatric history form asks for the school, grade, subjects below grade level, and whether the child has a 504 plan or an IEP.
Why does the eye doctor ask about reading symptoms?
The American Optometric Association guideline calls the patient history the first part of the examination. Its suggested questions cover eyestrain, headaches, and print that blurs or doubles during reading.
Is there a vision therapy intake form template?
The sample questions on this page show a typical set.
What happens after the form is completed?
The optometrist reviews the answers before testing. AI Doctor only collects them; it does not decide whether vision therapy is needed.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
