Dyop Color Visual Response
Clinical data capture form for quantifying color perception as associated with potential symptoms of dyslexia, migraines, and epilepsy.
Clinical Email Address of Practice *
Date of Survey *
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Patient ID number and initials *
Patient Gender *
Patient Age *
Race *
Binocular acuity endpoint for a Black/White-on-Gray Dyop
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Binocular acuity endpoint for a Blue on Black Dyop
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Binocular acuity endpoint for a Green-on-White Dyop
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Binocular acuity endpoint for a Blue-on-Gray Dyop
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Binocular acuity endpoint for a Green-on-Gray Dyop
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Binocular acuity endpoint for a Red-on-Gray Dyop
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Family History of Symptoms *
Required
Diagnosis Group *
Comments
Notes
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