Vision Development Center - New Patient Forms

Welcome

How To Use Online Forms
Welcome to the online forms section of the Vision Development Center website.

These forms allow you to save time by providing important information prior to your next office visit. The information you provide here will be added to our patient management system to better formulate your treatment plan.

Please ensure you complete the required sections in the following tabs:
  • Demographics
  • Medical History (Med Hist Tab)
Optional tabs, to be completed depending on the patient or situation are:
  • Insurance 1 & 2 (if you would like your insurance billed as a courtesy)
  • Adult Symptom Checklist (ASC Tab)
  • Child Symptom Checklist (CSC Tab)
  • Head Trauma Case History (HTCH Tab)
Please complete as much information as possible, and when finished click the 'Submit' button in the 'Submit' tab. If at any time you need to return to the Vision Development Center website, click here.

Demographics

Personal Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information
Is The Billing Address the Same?
TitleFirstLastMISuffix
Address
CityStateZipCode
Home Phone:
Work Phone:

Ins 1

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Ins 2

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Med History

Were you referred to our office? Yes No By Whom?
Names and Birth Dates of Spouse and Dependents
Name Birthdate
Is There Any History of the Following?
Patient Family
Diabetes
High Blood Pressure
Heart Disease
Gastrointestinal Problems
Musculoskeletal Problems
Asthma/Allergies
Neurological Problems
Ear, Nose, Throat
Head Injury/Trauma
Cataracts
Glaucoma
Lazy Eye (amblyopia)
Eye Turn (strabismus)
Eye Disease
Eye Surgery
Eye Infection
Brief Medical History Questions
Physician's name Date of last evaluation
For what problems/conditions?
Results and recommendations:
Medications currently using including vitamins and supplements:
For what conditions?
List allergies to foods or medications:
Main reason for exam today:
Date of last evaluation: Doctor's name:
Reason for exam:
Results and recommendations:
Were glasses, contacts or other optical devices prescribed?
If yes are they used? If yes, when?
If no why not?
Are there any problems with your current optical prescription?
If yes, please describe:

ASC

Do you experience any of the following?
Headaches Yes No If yes, when?
Blurred vision (focus goes in and out) Yes No If yes, when?
Double vision Yes No If yes, when?
Nausea when doing visual tasks Yes No If yes, when?
Motion/car sickness Yes No If yes, when?
Halos around lights Yes No If yes, when?
Need for bright light Yes No If yes, when?
Need for dim light Yes No If yes, when?
Eyes "hurt" or "tired" Yes No If yes, when?
Eyes itch, burn or tear Yes No If yes, when?
Eyes frequently reddened Yes No If yes, when?
Closing or covering one eye Yes No If yes, when?
Lose place while reading Yes No If yes, when?
Poor reading comprehension Yes No If yes, when?
Difficulty managing attention while reading Yes No If yes, when?
Head tilt when reading or writing Yes No If yes, when?
Avoiding reading Yes No If yes, when?
Head close to paper when reading/writing Yes No If yes, when?
Moves head when reading Yes No If yes, when?
Frequent blinking Yes No If yes, when?
Bothered by light Yes No If yes, when?
Confuses letters or words Yes No If yes, when?
Reverses letters or words Yes No If yes, when?
Left/Right confusion Yes No If yes, when?
Skips, rereads or omits words Yes No If yes, when?
Loses place while reading Yes No If yes, when?
Vocalize while reading silently Yes No If yes, when?
Slow reader Yes No If yes, when?
Uses finger as marker Yes No If yes, when?
Writes or prints poorly Yes No If yes, when?
Writes neatly but slowly Yes No If yes, when?
Frequent erasures Yes No If yes, when?
While reading, letters/words appear to float around Yes No If yes, when?
Comprehension decreases over time Yes No    
Visual activities
Hours per week Approximate viewing distance
Nintendo, games etc.
Television
Computer use
Does your work or leisure time activities involve any eye hazards? Yes No
If yes, is protective eyewear worn?
Do you use a computer? Yes No If yes, how many hours a day?
Please enter the approximate computer working distances:
Eyes to the screen: Eyes to the keyboard: Eyes to the source document:
Please describe any problems you have with your current glasses or contact lenses for computer work:
Any visual symptoms after using your computer?
Does your work/leisure activities require comprehension of the written word? Yes No
If yes, describe:
Have you ever had any blows or injuries to your head, eyes or neck? Yes No
If yes, describe:
Do you feel your vision hinders you in any way? Yes No
If yes, how:

CSC

Present situation
Why do you feel your child needs a visual evaluation?
How long has this problem / difficulty been observed?
Is there any evidence from the school, psychological, or other tests that indicates some visual malfunction may be present? Yes No
If yes, what?
Has your child reported any of the following:
Headaches Yes No If yes, when?
Blurred vision (focus goes in and out) Yes No If yes, when?
Double vision Yes No If yes, when?
Nausea when doing visual tasks Yes No If yes, when?
Motion / car sickness Yes No If yes, when?
Halos around lights Yes No If yes, when?
Need for bright light Yes No If yes, when?
Need for dim light Yes No If yes, when?
Eyes "hurt" or "tired" Yes No If yes, when?
Eyes itch, burn or tear Yes No If yes, when?
Eyes frequently reddened Yes No If yes, when?
Closing or covering one eye Yes No If yes, when?
Lose place while reading Yes No If yes, when?
Poor reading comprehension Yes No If yes, when?
Difficulty managing attention while reading Yes No If yes, when?
Head tilt when reading or writing Yes No If yes, when?
Avoid reading Yes No If yes, when?
Head close to paper when reading / writing Yes No If yes, when?
Moves head when reading Yes No If yes, when?
Prefers being read to Yes No If yes, when?
Frequent blinking Yes No If yes, when?
Bothered by light Yes No If yes, when?
Confuses letters or words Yes No If yes, when?
Reverses letters or words Yes No If yes, when?
Left/Right confusion Yes No If yes, when?
Skips, rereads or omits words Yes No If yes, when?
Vocalize while reading silently Yes No If yes, when?
Slow reader Yes No If yes, when?
Uses finger as marker Yes No If yes, when?
Writes neatly but slowly Yes No If yes, when?
Writes or prints poorly Yes No    
Awkward or immature pencil grip Yes No    
Frequent erasures Yes No    
Difficulty copying from the chalkboard Yes No    
While reading letters / words appear to float around Yes No    
Frequent eye rubbing Yes No If yes, when?
Frequent sties Yes No If yes, when?
Comprehension decreases over time Yes No If yes, when?
Does not support paper when writing Yes No If yes, when?
Tires easily Yes No If yes, when?
Difficulty recognizing same word on different page Yes No If yes, when?
Poor word attack skills Yes No If yes, when?
Difficulty with memory Yes No If yes, when?
Remembers better what hears than sees Yes No If yes, when?
Responds better orally than by writing Yes No If yes, when?
Seems to know material but does poorly on tests Yes No If yes, when?
Dislikes / avoids near tasks Yes No If yes, when?
Short attention span / loses interest Yes No If yes, when?
Poor large motor coordination Yes No If yes, when?
Poor fine motor coordination Yes No If yes, when?
Difficulty with scissors / small hand tools Yes No If yes, when?
Dislikes / avoids sports Yes No If yes, when?
Difficulty catching / hitting a ball Yes No If yes, when?
Television Viewing / Leisure Time Activities
Hours Per Week Approximate Viewing Distance
Nintendo games, etc
Television
Computer Use
What other activites occupy your childs leisure time?
Are there any activites your child would like to participate in but doesn't?
Please explain:
Developmental History
Full term pregnancy? Yes No
Did the mother experience any health problems during the pregnancy? Yes No
If yes, please explain:
Normal Birth? Yes No
Any complications before, during or immediately following delivery? Yes No
If yes, please explain:
Birth weight: Apgar scores @ birth: After 10 minutes:
Were forceps used? Yes No
Was there ever any reason for concern over your child's general growth and development? Yes No
If yes, why?
Did your child crawl (stomach on floor)? Yes No At what age?
Did your child creep (on all fours)? Yes No At what age?
If not, describe:
At what age did your child walk?
Was child active? Yes No
Speech: First Words: At what age?
Was early speech clear to others? Yes No
Is speech clear now? Yes No
Visual History
Has your child's vision been previously evaluated? Yes No
If so, Doctor's name: Date of last evaluation:
Reason for examination:
Result and recommendations:
Were glasses, contact lenses, or other optical devices recommended? Yes No
If yes, what?
Are they used? Yes No
If yes, when?
If not used, why not?
Members of the family who have had visual attention and the reason?
Name Age Visual Situation
School
Age at time of entrance to: Preschool Kindergarten First Grade
Does your child like school? Yes No
Specifically describe any school difficulties:
Has your child changed schools often? Yes No
If yes, when?
Has a grade been repeated? Yes No
If yes, which and why?
Does you child seem to be under tension or extreme pressure when doing school work? Yes No
Has your child had any special tutoring, therapy, and/or remedial assistance? Yes No
If yes, when?
Where and from whom?
How long?
Results:
Does your child like to read? Yes No
Voluntarily? Yes No
Does your child read for pleasure? Yes No
What?
What is your child's attitude towards reading, school, his/her teachers, other youngsters?
Overall school work is: above average average below average
Which subjects are:
Above average:
Average:
Below Average:
Does your child need to spend a lot of time/effort to maintain this level of performance? Yes No
How much time on average does your child spend each day on homework assignments?
To what extend do you assist your child with homework?
Do you feel your child is achieving up to potential? Yes No
Does the teacher feel your child is achieving up to potential? Yes No
General Behavior
Are there any behavior problems at school? Yes No
If yes, what?
Are there any behavior problems at home? Yes No
If yes, what?
What causes these problems?
Child's reaction to fatigue? sag irritable other
Child's reaction to tension? sag irritable other
Does your child say and/or do things impulsively? Yes No
Is your child in constant motion? Yes No
Can your child sit still for long periods? Yes No
Family and Home
Fathers Name: Birth Date:
Address (if different from child's):
Phone:
Business Name: Occupation:
Business Address: Phone:
City: State: ZIP:
Mothers Name: Birth Date:
Address (if different from child's):
Phone:
Business Name: Occupation:
Business Address: Phone:
City: State: ZIP:
Please indicate which adult he/she lives with:
Mother Father Stepmother Stepfather
Foster Parents Adoptive Parents Grandmother Grandfather
Aunt Uncle Other
Does your child spend time with any other person not in the home? Yes No
Please explain:
Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness? Yes No
If yes, at what age?
Does your child seem to have adjusted? Yes No
Was counseling / therapy undertaken? Yes No
If yes, is it on-going? Yes No
Is family life stable at this time? Yes No
If no, please explain?
Did father or anyone in fathers family have a learning problem? Yes No
If yes, who?
Did mother or anyone in mother's family have a learning problem? Yes No
If yes, who?
Do you, or did any of the other children in the family have learning problems? Yes No
If yes, who?
To what extent?
Give a brief description of your child as a person:
Is there any other information you feel would be helpful / important in our treatment of your child?

HTCH

Personal Information
Name: DOB: Age: Date:
Address: City: State: ZIP:
SSN: Referred by:
Current medications:
Allergies:
Type of Accident
Motor Vehicle
Type of vehicle you were in:
If other vehicle(s) involved, list types(s)
Where were you sitting?
Front Seat Left Side Middle
Back Seat Right Side Unusual Position
Which restraints were used? (check all that apply)
lap shoulder car seat
booster seat air bag
Speed of vehicle you were in:
Speed of other object or vehicle?
Did other vehicle hit another object? Yes No
Did other vehicle hit your vehicle? Yes No
If yes, where was your vehicle hit?
Head On Toward Front Drivers Side
Rear Ended Toward Rear Passenger Side
Did you experience whiplash? Yes No
Did you hit your head? Yes No If yes, on what?
Other Accidents
Type (example: Home, Industrial, Fall, Hit by Object, etc.):
Please describe:
Toxic
Type (example: medication related, drug abuse, poison, etc.):
Please describe:
Anoxic
Type (example: drowning, CO2, anesthesia, cord around neck, etc.):
Please describe:
Vascular
Type (example: stroke, aneurysm, hemorrhage, etc.):
Please describe:
Other
Other (please explain):
Please describe:
Head Injury Description
What part of your head was affected?
Forehead Right Side Top of Head
Back of Head Left Side Face
Were you unconscious? Yes No If yes, for how long?
Comments:
Initial Care
Did you see a doctor concerning the accident? Yes No
Whom did you see?
When?
Where?
What were you or your family told?
Comments:
Subsequent / Other Professional Care
What kind of professional care for your injuries / trauma have you received or are you receiving?
Family Physician
Chiropractor
Neurologist
Emergency Room Doctor
Occupational Therapist
Physical Therapist
Speech Therapist
Audiologist / Otolaryngologist
Psychologist
Physiatrist
Psychiatrist
Optometrist
Opthalmologist
Osteopath
Massage Therapist
Other
Symptoms Immediately Following the Accident
Double Vision Headache Loss of Memory
Blurred Vision Pain In or Around Eyes Vomiting
Dizziness Restrictive Field of View Loss of Balance
Disorientation Flashes of Light Restricted Motion
Comments:
Difficulties Following Accident
Work Related
Please describe:
Hobbies / Avocational
Please describe:
Recreational / Social
Please describe:
Other
Please describe:
Other Information
Please take the time to share with us anything else that you feel is relevant:
Please describe:
Subsequent Symptoms / Experiences
Please consider each symptom in all the columns that apply. Place a check beside MIN if the symptom is only minimally present or MAX if the symptom is very significant.
Symptom Was present before accident New symptom since accident
Blurred vision, distance viewing Min Max Min Max
Blurred vision, near viewing Min Max Min Max
Slow to shift focus, near to far to near Min Max Min Max
Difficulty taking notes Min Max Min Max
Pulling or tugging sensation around eyes Min Max Min Max
Difficulty moving or turning eyes Min Max Min Max
Pain with movement of the eyes Min Max Min Max
Wandering eye Min Max Min Max
Double vision Min Max Min Max
Loss of place while reading Min Max Min Max
Discomfort while reading Min Max Min Max
Unable to sustain near work / reading for adequate periods Min Max Min Max
General fatigue while reading Min Max Min Max
Eyes get tired while reading Min Max Min Max
Headaches Min Max Min Max
Pain in or around the eyes Min Max Min Max
Easily distracted Min Max Min Max
Decreased attention span Min Max Min Max
Reduced concentration ability Min Max Min Max
Difficulty remembering what has been read Min Max Min Max
Difficulty remembering names of objects Min Max Min Max
Difficulty remembering people's names Min Max Min Max
Difficulty recalling information known in the past Min Max Min Max
Difficulty recognizing formerly familiar objects Min Max Min Max
Difficulty recognizing formerly familiar people Min Max Min Max
Difficulty remembering things heard Min Max Min Max
Difficulty remembering things seen Min Max Min Max
Dizziness Min Max Min Max
Poor coordination Min Max Min Max
Clumsiness Min Max Min Max
Loss of balance Min Max Min Max
Poor eye-hand coordination Min Max Min Max
Poor handwriting Min Max Min Max
Poor posture Min Max Min Max
Head tilt Min Max Min Max
Face turn Min Max Min Max
Covering, closing one eye Min Max Min Max
Disorientation Min Max Min Max
Get lost often Min Max Min Max
Bothered by movement around you Min Max Min Max
Bothered by noises around you Min Max Min Max
Bothered by being touched Min Max Min Max
Abnormal general fatigue Min Max Min Max
Reduced depth perception Min Max Min Max
Light sensitivity Min Max Min Max
Flashes of light Min Max Min Max
Floaters in field of view Min Max Min Max
Restricted field of vision Min Max Min Max
Tunnel vision Min Max Min Max
"Curtain" billowing into field of view Min Max Min Max

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