reception@okanaganvisiontherapy.ca

1 (236) 420-4448

Home
About Us
- About
- Testimonials
Treatments
Symptoms
Kids Glasses
Resources
Locations
Contact

Intake Form

Book an Appointment

WELCOME TO OKANAGAN VISION THERAPY!

1General Information

2Contact Information

3Medical Information

General Information
Name*
First Last
Preferred Name
Date of Birth*
Month
Day
Year
Personal Health Number*
Parent/Guardian Name(s) (If applicable)
CAPTCHA

Contact Information
Address*
Street Address Address Line 2 City Postal Code
Home Phone
Cell Phone
Email
By checking and signing below, I consent to Okanagan Vision Therapy sending me emails containing:
- Recalls and appointment times
- Informational emails
- I understand that I can withdraw my consent at any time by contacting Okanagan Vision Therapy.
Additionally, by signing below, I hereby authorize the Medical Services Plan (MSP) to pay Dr. Paul Rollett: MSP Practitioner #: 87475 directly for all reimbursements for benefits payable under the Medical and Health Care Services Regulation for care provided to me by the office of said practitioner.
Signature
Date
Month
Day
Year

Medical Information
Please select the reason for your appointment*
Detail of the reason for today's appointment*
Medications
Convergence Insufficiency Symptom Survey
Please complete this questionnaire. After each symptom listed, check the option that best describes how often you experience that particular problem.
Do your eyes feel tired when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do your eyes feel uncomfortable when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you have headaches when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you feel sleepy when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you lose concentration when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you have trouble remembering what you read?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you have double vision when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you feel like you read slowly?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do your eyes ever hurt when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do your eyes feel sore when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you feel “pulling” feeling around your eyes when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you notice the words blurring or coming in and out of focus when reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you lose your place while reading or doing close work?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Do you have to reread the same line of words when reading?*
- Never
- Not Very Often
- Sometimes
- Fairly Often
- Always
Visions Related Learning Difficulty
School
Grade
Teacher
Primary Concerns (check all that apply)
Reading
- Yes
Please Explain
Writing
- Yes
Please Explain
Classroom Performance
- Yes
Please Explain
Attention
- Yes
Please Explain
Is your child currently working with any other professionals (ie: Tutor, Occupational Therapist, Psychologist, etc)?
Developmental History (Please briefly comment on the following):
Pregnancy
Developmental Milestones
Acquired Brain Injury
Claim
- ICBC Claim
- WorkSafeBC Claim
- Neither
Date of Injury/Accident
Month
Day
Year
Occupation and Return to Work Status
Claim Number
Case Manager
Lawyer (if applicable)
Law Firm
Type of Injury/accident (brief description)
What part of the head was affected?
Did you lose consciousness?
- Yes
- No
For How Long?
Persistent Visual Symptoms
(ie: Headaches, Eyestrain, Light Sensitivity, Blurred Vision, Double Vision, Visual Loss)
Additional professionals involved (ie: Occupational Therapist, Physiotherapist, Psychologist, Chiropractor, Neurologist, Physician, etc)
Strabismus (Eye-Turn) or Amblyopia (Lazy-Eye)
At what age was the issue first discovered?
Age when glasses were first prescribed
Glasses are worn
- Full Time
- Part Time
Is your son/daughter currently working with any other professionals (ie: Occupational Therapist, Physiotherapist, Ophthalmologist, etc)?
Developmental History (Please briefly comment on the following):
Pregnancy
Developmental Milestones
Sport Vision Assesment
Primary Sport
Position
Team
Head Coach
Athletic Goals (ie: University, Professional)
Areas of Vision Concern
Authorized Parties
Please indicate the name and email or fax # for all parties you authorize us to send your Functional Vision Evaluation findings to. This information must be provided prior to your in office visit.
Authorized recipients of Functional Vision Evaluation findings
Name Email or Fax#

While patients are very happy about their results, we often hear the frustration about the lack of public and professional awareness. Our patients and their families would like to share their experiences in order to raise awareness and help others get the help they need!

Quick Links

Home
About Us
Treatments
Symptoms
Kids Glasses
Resources
Locations
Contact

Useful Links

Testimonials
Careers
NeuroVisual Trainer
Blog
Screening Test & Questionnaire
FAQ
Referrals

Visiting Hours

Monday to Friday : 9am – 5pm

Saturday : 9am – 4pm

Sunday : CLOSED

Contact

Phone

1 (236) 420-4448

Email

reception@okanaganvisiontherapy.ca

Fax

1 (778) 699-2067

Locations

Kelowna | Vernon | Nelson | Penticton
Revelstoke | Salmon Arm

We acknowledge that our work takes place on the traditional, ancestral, and unceded territory of the Syilx/Okanagan People. We are grateful to live, work, and connect in this beautiful region.

Copyright 2025 All rights reserved. Web Design, Photography, SEO by Hiilite