Online Forms

Demographics

Insurance

General Medical History

Review of Systems

Ocular History

Vision Therapy

Patient Information

Title	First*	Last*	MI	Suffix	Preferred Name

Address*
City	St	Zip
Cell Phone*
or Home Phone (optional)
Email*
Preferred Contact By
DOB (mm/dd/yyyy)*
Sex	Female Male
Occupation \| Grade
Employer \| School
If Minor, Guardian:

How did you find us? Yelp? Google? A friend's recommendation?

Please select the General Medical History tab at the top to continue filling out your form.

Vision Insurance Information

Insurance Name:
Insurance ID:
Insurance Policy Group:

Please check here if you are not the primary on the account: Not Primary

Please fill in the following information for the Primary Member on the account

Name:	Last, First, MI
Patient's relationship to Primary Member:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
* SSN:
Employer/School:

* We are unable to authorize your insurance benefits without this information. Please provide at least the last 4 digits.

Medical Insurance Information

Insurance Name:
Insurance ID:
Insurance Policy Group:

Please check here if you are not the primary on the account: Not Primary

Please fill in the following information for the Primary Member on the account

Name:	Last, First, MI
Patient's relationship to Primary Member:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
* SSN:
Employer/School:

* We are unable to authorize your insurance benefits without this information. Please provide at least the last 4 digits.

General Medical History

Primary physician's name & phone
When was your last physical exam?

Check the box for any conditions that apply (or leave blank if not applicable):

If *YOU* are diabetic, when were you diagnosed?		Last A1C level?
Are you Pregnant or Nursing?

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status
Alcohol Use
Do you live alone?

Please list any problems you are currently having anywhere, from head to toe:

(leave blank if not applicable)

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Please select the Ocular History tab at the top to continue filling out your form.

Purpose of Visit & Ocular History

Who was your previous eye doctor?
When was your last eye exam?

Check the box for any conditions that apply:

List any major eye injuries, infections or surgeries and approx dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

List any vision complaints you are currently having such as:

blurred vision, headaches, eyestrain, double vision, or losing your place when reading
itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

How many hours/day do you spend using the computer, reading books/magazines, and/or playing sports?:

Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?

Please select the Vision Therapy tab at the top to continue filling out your form.

Describe (type, when were you diagnosed, etc)

Hypertension

Cardiovascular

Vision Therapy (leave blank if not applicable)

General Information

Patient Name:

Nickname:

Age:

DOB:

Mother's Name:

Father's Name:

Guardian's Name(s):

Child Resides With:

at (address):

Name of School:

Grade:

Referred By:

Why do you wish to be evaluated?:

List any complaints your child makes concerning his/her vision:

At what age did this problem begin?:

Has the problem been better or worse?:

Explain:

Does anyone else in the family have a similar problem?:

Has there been previous treatment?:

Does the child feel like they have a problem?:

Symptoms and Observations

Have you or your child noticed any of the following (while wearing their correction, if glasses have been prescribed)? Please mark symptoms which occur frequently with TWO checks and those which occur occasionally with ONE check.

	Unusual blinking or eye rubbing
	Watering or bloodshot eyes
	Double vision
	Eyelid twitch or muscle spasm
	Eye turn in or out
	Squint, close or cover one eye
	Carsickness
	Headaches
	Blurred vision distance or near
	Avoid near tasks such as reading
	Fatigue easily
	Frequent head turning while reading
	Reread or omit words
	Print "runs together" or words "jump"

	Dizziness
	Eyes bothered by light
	Print comes in and out of focus
	Difficulty tracking moving objects, balls, etc.
	Short attention span
	Make errors copying
	Writing is crooked or poorly spaced
	Poor Spelling
	Confuse right and left direction
	Eyes Hurt or tired after close work
	Confuse or reverse letters, numbers or words
	Poor reading comprehension
	Head too close to paper when reading or writing
	Unusual posture/head tilt when reading or writing
	Skip lines or lose place while reading or copying

School History

Please arrange to bring a copy of special school testing if any has been completed.

Does she/he like school?:

Teacher?:

Name of Teacher:

May we contact them?:

School work is: Above average Average Below Average

Do you feel like she or he is working up to their potential?:

What subjects are easy for your child?:
What subjects are difficult for your child?:

Specifically describe any school difficulties:

Has a grade been repeated?: Yes No

If yes, which grade(s)?:

Does she/he attend any special classes/resources?: Yes No

if yes, explain:

Has attendance been regular?: Yes No

If no, explain:

Does your child like to read?: Yes No

Does your child prefer to be read to rather than reading on his or her own?:

Behavior

Are there any behavior problems? If yes, what causes these problems?

Medical History

Health at Present: Excellent Good Fair Poor

When was the last vision examination?

By Doctor:

Were glasses prescribed?: Yes No Were recommendations made?: Yes No

If yes, explain:

Was the treatment program followed?: Yes No Was the treatment effective?: Yes No

Has a vision therapy program been recommended?: Yes No Completed?: Yes No

Are there any indications of hearing or speech related problems?: Yes No

If yes, explain:

Developmental History

List any drugs, medications or complications during pregnancy:

Length of Pregnancy:

Normal Birth?:

Complications before, during or following delivery?:

Did your child crawl?

Stomach on floor:		Age:
On hands and knees:		Age:

Was there anything unusual about crawling or early motor development?:

At what age did your child walk?:

Did arms or legs require special braces?:

Can most children his or her age run faster?:

Throw or catch a ball better?:

Which hand does your child use for -
Eating?: Right Left Writing?: Right Left Throwing?: Right Left

Has she/he always used the same hand?: Yes No

Was any guidance given? If yes, explain:

Which foot does she/he use for kicking?: Left Right Hopping?: Left Right

At what age were your child's first words?:

Was early speech clear to others?:

Is it clear now?:

Interests and Abilities

Does she/he have any special abilities? (art, music, etc.):
Favorite activities - What does your child find most rewarding?:

Give a brief description of your child's personality:

Evaluation

Grade:		School:
Teacher:		Subject:

ADD/ADHD
Autism
Learning Disorder
Other Delays:
Therapies:

Symptom Checklist:

Please check all the symptoms that apply for the patient:

HA

Diplopia

Crossing Eye

Wandering Eye

Lazy Eye

Fatigue/strain w/reading

Other

Letter reversals

Losing place while reading

Omitting small words when reading

Transposing letters/#s (ie 12 for 21)

Dislike reading

Words swim/move/jump

Slow reader

Poor eye hand cord

Can't keep eye on ball

Poor handwriting

Poor memory

Can't visualize

R/L confusion

Difficulty copying from board

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