|Vestibular/Ocular Motor Test: ||Not Tested ||Headache 0–10 ||Dizziness 0–10 ||Nausea 0–10 ||Fogginess 0–10 ||Comments |
|BASELINE SYMPTOMS: || |
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|Smooth Pursuits || || || || || || |
|Saccades—Horizontal || || || || || || |
|Saccades—Vertical || || || || || || |
|Convergence (Near Point) || || || || || || |
(Near Point in cm):
Measure 1: ______
Measure 2: ______
Measure 3: ______
|VOR—Horizontal || || || || || || |
|VOR—Vertical || || || || || || |
|Visual Motion Sensitivity Test || || || || || || |
Interpretation: This test is designed for use with subjects ages 9–40. When used with patients outside this age range, interpretation may vary. Abnormal findings or provocation of symptoms with any test may indicate dysfunction—and should trigger a referral to the appropriate health care professional for more detailed assessment and management.
Equipment: Tape measure (cm); Metronome; Target w/14 point font print.
Baseline Symptoms—Record: Headache, Dizziness, Nausea & Fogginess on 0–10 scale prior to beginning screening
Smooth Pursuits—Test the ability to follow a slowly moving target. The patient and the examiner are seated. The examiner holds a fingertip at a distance of 3 feet from the patient. The patient is instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction 1.5 feet to the right and 1.5 feet to the left of midline. One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed. The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go fully from right to left. The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.5 feet above and 1.5 feet below midline for 2 complete repetitions up and down. Again, the target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 seconds to move fully downward. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.
Saccades—Test the ability of the eyes to move quickly between targets. The patient and the examiner are seated.
Horizontal Saccades: The examiner holds two single points (fingertips) horizontally at a distance of 3 feet from the patient, and 1.5 feet to the right and 1.5 feet to the left of midline so that the patient must gaze 30 degrees to left and 30 degrees to the right. Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move back and forth to the starting position, and 10 repetitions are performed. Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.
Vertical Saccades: Repeat the test with 2 points held ...