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Phyllis Liu, O.D., FCOVD

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Neuro-Optometric Rehabilitation Questionnaire

Patient Name(Required)
MM slash DD slash YYYY
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Please check the signs and symptoms that best describe how you feel or are performing.
Focusing Deficiencies
Eye Pointment Deficiencies
Eye Movement Deficiencies
Visual - Spatial Deficiencies
Visual Analysis Deficiencies
Visual Field Deficiencies
Sensory Integration Deficiencies
This field is for validation purposes and should be left unchanged.