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
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
FL
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
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
Single
Married
Separated
Divorced
Widowed
Unknown
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Manes, Regina
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address
City
State
ZipCode
FL
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Ins 1
Insurance Information
Insurance Name:
None
AARP Healthcare Option
Aetna
Amerigroup
Anthem
BCBS of FL
Cigna
Humana Tricare
Medicare
United Health Care
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:
None
AARP Healthcare Option
Aetna
Amerigroup
Anthem
BCBS of FL
Cigna
Humana Tricare
Medicare
United Health Care
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
Submit
Submit
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