Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Misc/Guardian

TBI Followup

Date of Last TWV Evaluation

Additional Notes

Current Providers

Frequency of Followup

Updates / New Recommendations

Neurologist

Occupational Therapist

Physical Therapist

Chiropractic

Manual Therapy / Massage

Nutritionist

Functional Neurology

Acupuncture

Counselor / Therapist

Neuropsychologist

Other

Symptoms

For the following section, please enter the most appropriate number that best matches your observations

0-Never | 1-Seldom | 2-Occasionally | 3-Frequently | 4-Always

Eyesight Clarity

Distance vision Blurred and not clear - even with lenses

Near vision blurred and not clear - even with lenses

Clarity of vision changes or fluctuates during the day

Difficulty shifting focus from near to far (lag of focus, takes time to clear)

Poor night vision / can't see well to drive at night

Flashes, floaters, other (visual snow, grainy, etc)

Additional Notes

Visual Comfort

Eye discomfort/sore eyes/eyestrain/pain/eye fatigue

Headaches

Feel pulling around the eyes

Eye redness, burning, watering, itching

Fatigue at the end of day

Additional Notes

Doubling

Double vision

Have to close or cover one eye to see clearly

Print moves out of focus when reading

Additional Notes

Light Sensitivity

Outdoor light is too bright â have to use sunglasses

Indoor / fluorescent lighting is bothersome or annoying

Additional Notes

Dry Eyes

Eyes feel dry and sting

Have to rub eyes a lot

Additional Notes

Depth Perception

Clumsiness / misjudge where the objects really are

Lack of confidence walking / missing steps / stumbling

Additional Notes

Peripheral Vision

Avoids crowds / can't tolerate 'visual' busy places

Tunnel Vision or partial vision loss

Notices objects off to the side when nothing is there

Additional Notes

Reading

Short attention span / easily distracted when reading

Difficulty / slowness reading and writing

Poor reading comprehension / can't remember what was read

Confusion of words

Lose place/have to use finger/words jump on the page

Additional Notes

Auditory

Ringing in the ears

Bothered by noises

Additional Notes

Vestibular

Dizziness

Vertigo (rock and sway like you are on a boat, spinning)

Motion / car sickness (when you are moving)

Movement of objects around you are bothersome

Busy patterns / stripes (clothes / carpet) are bothersome

Additional Notes

Attention

Confusion / disorientation

Difficulty with memory

Brain Fog (mental focus is hard to maintain)

Additional Notes

Sleep

Difficulty with sleep

Falling asleep

Staying asleep

Average number of hours/sleep per night

Attempted interventions (sleep routines, bilateral tones, etc.)

Additional Notes

Proprioceptive/Kinesthetic

Proprioceptive / Kinesthetic

Bothered by textures, touch, pressures

Awkward Poor balance

Additional Notes