Binocular Vision History Assessment System

Age

Gender

Occupation

Handedness

Chief Complaint

Onset

Severity (1-10) 5

Visual Demands Assessment

Computer Use (hours/day)

Reading (hours/day)

Sports Participation

CISS (Convergence Insufficiency Symptom Survey)

COVD-QOL Assessment

Symptom Characteristics

Symptoms occur:

Morning Evening Near tasks Distance tasks

Triggering Factors

Relieving Factors

Symptom Progression

Functional Impact on Daily Activities

Previous Treatments Attempted

Response to Modifications

Improves with rest Improves when covering one eye Tried prism glasses Tried reading glasses

Previous Eye Surgeries

Strabismus surgery Cataract surgery Refractive surgery Retinal surgery None

Childhood Vision History

History of amblyopia History of strabismus/eye turn Eye patching therapy Previous vision therapy

Refractive Error History

Eye Injuries or Trauma

Birth History

Premature birth Birth complications Low birth weight Normal birth

Developmental Milestones

Delayed milestones Learning difficulties ADHD diagnosis Reading problems

Sports Performance

Family Vision History

Strabismus/eye turn Amblyopia/lazy eye High myopia Astigmatism

Family Learning/Neurological History

Learning disabilities ADHD Neurological conditions

Medical Conditions

Neurological conditions Head injuries/concussions Diabetes Thyroid disorders Autoimmune conditions

Binocular Vision History Assessment

Patient Demographics & Chief Complaint

Visual Demands Assessment

Detailed Symptom Assessment

CISS (Convergence Insufficiency Symptom Survey)

COVD-QOL Assessment

Symptom Characteristics

History of Present Illness

Past Ocular History

Developmental & Birth History

Family History

Medical History & Medications

NSBVA-Specific Assessment

Convergence Symptoms

Accommodative Symptoms

Sensory Adaptation

AI Clinical Decision Support

Diagnostic Probabilities

Recommended Clinical Tests

Clinical Alerts

Assessment Scores