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Dyop Color Visual Response
Clinical data capture form for quantifying color perception as associated with potential symptoms of dyslexia, migraines, and epilepsy.
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* Indicates required question
Clinical Email Address of Practice
*
Your answer
Date of Survey
*
MM
/
DD
/
YYYY
Patient ID number and initials
*
Your answer
Patient Gender
*
Male
Female
Prefer not to say
Other:
Patient Age
*
Your answer
Race
*
White or Caucasian
Black African
Hispanic or Latino
Asian
American Indian or Native American
Native Hawaiian or other Pacific Islander
Another Race
Other:
Binocular acuity endpoint for a Black/White-on-Gray Dyop
Choose
20/15 or 6/4.5
20/18 or 6/5.5
20/20 or 6/6
20/25 or 6/7.5
20/30 or 6/10
20/40 or 6/12
20/50 or 6/15
20/60 or 6/18
20/70 or 6/21
20/80 or 6/24
20/90 or 6/27
20/110 or 6/34
20/130 or 6/40
Binocular acuity endpoint for a Blue on Black Dyop
Choose
20/15 or 6/4.5
20/18 or 6/5.5
20/20 or 6/6
20/25 or 6/7.5
20/30 or 6/10
20/40 or 6/12
20/50 or 6/15
20/60 or 6/18
20/70 or 6/21
20/80 or 6/24
20/90 or 6/27
20/110 or 6/34
20/130 or 6/40
Binocular acuity endpoint for a Green-on-White Dyop
Choose
20/15 or 6/4.5
20/18 or 6/5.5
20/20 or 6/6
20/25 or 6/7.5
20/30 or 6/10
20/40 or 6/12
20/50 or 6/15
20/60 or 6/18
20/70 or 6/21
20/80 or 6/24
20/90 or 6/27
20/110 or 6/34
20/130 or 6/40
Binocular acuity endpoint for a Blue-on-Gray Dyop
Choose
20/15 or 6/4.5
20/18 or 6/5.5
20/20 or 6/6
20/25 or 6/7.5
20/30 or 6/10
20/40 or 6/12
20/50 or 6/15
20/60 or 6/18
20/70 or 6/21
20/80 or 6/24
20/90 or 6/27
20/110 or 6/34
20/130 or 6/40
Binocular acuity endpoint for a Green-on-Gray Dyop
Choose
20/15 or 6/4.5
20/18 or 6/5.5
20/20 or 6/6
20/25 or 6/7.5
20/30 or 6/10
20/40 or 6/12
20/50 or 6/15
20/60 or 6/18
20/70 or 6/21
20/80 or 6/24
20/90 or 6/27
20/110 or 6/34
20/130 or 6/40
Binocular acuity endpoint for a Red-on-Gray Dyop
Choose
20/15 or 6/4.5
20/18 or 6/5.5
20/20 or 6/6
20/25 or 6/7.5
20/30 or 6/10
20/40 or 6/12
20/50 or 6/15
20/60 or 6/18
20/70 or 6/21
20/80 or 6/24
20/90 or 6/27
20/110 or 6/34
20/130 or 6/40
Family History of Symptoms
*
Mother with Dyslexia
Father with Dyslexia
Sibling with Dyslexia
Mother with Migraines
Father with Migraines
Sibling with Migraines
Mother with Epilepsy
Father with Epilepsy
Sibling with Epilepsy
Required
Diagnosis Group
*
No dyslexia
Moderate dyslexia
Severe dyslexia
Severe Dyslexia - visual and auditory
Borderline dyseidesia
Dysphonesia
Borderline Dysphoneidesia
Dysphoneidesia
Mild Dysphoneidesia
Possible dyslexia
Dyscalculia
Severe dyscalculia
Other:
Comments
Your answer
Notes
Your answer
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