Adult History
When was your last eye exam:
Where:
Who is your Primary Care Physician:
Do you have any MEDICATION ALLERGIES?
Please list all MEDICATIONS you currently use (including over the counter, eye drops and supplements):
List all EYE SURGERIES or INJURIES:
Have you been diagnosed with any of the following EYE CONDITIONS (check all that apply)?
Other Eye Conditions:
Check any of the following symptoms you experience:
Eye Strain with Reading or Computer Work
If yes, complete reading/computer tab
Dizziness or Car Sickness
If yes, complete dizziness/motion sensitivity tab.
Other Eye Symptoms:
VISION HISTORY
What is your primary vision correction?
Have you ever worn Contact Lenses?
Are you interested in Contact Lenses?
Are you interested in Laser Vision Correction?
If yes, please bring your current prescription information with you
Are your Contact Lenses comfortable and working well for you?
Do you have additional glasses? (back up, reading, computer, sun, music, etc)
What is your primary occupation?
How many hours per day do you work on a computer?
List your hobbies or other activities:
CURRENT GENERAL HEALTH HISTORY
Do any of the following conditions apply to you?
Currently Pregnant
List any other conditions (such as Autism, Down Syndrome, ADD/ADHD, Hearing impaired, Speech impaired, Anxiety disorder etc...)
Do you use any of the following:
Alcohol
Tobacco
Recreational Drugs
FAMILY HISTORY
Is there a history of any of the following conditions in your immediate family?
Other Family History of Eye Conditions:
______________________________________________________________________________________________________________________________________________________
Were you referred to our office?
Whom may we thank for this referral?
Referral address:
Phone:
If not referred, how did you hear about us?
Strabismus/Amblyopia
(for children and adults with a lazy eye, eye turn or crossed or wandering eye)
At what age was the eye turn first noticed?
Did it start suddenly or gradually?
Which direction does the eye turn (check all that apply)?
Up
Down
Out
In
Which eye turns?
Right
Left
Both
Is the eye turn getting worse, better or no change?
When does the eye turn (always, what % of time, when tired, when ill, etc)?
Does the eye turn more when looking:
Do you ever notice one or both eyes shaking rapidly?
If patching treatment was prescribed, please describe at what age patching was started,
how it was done, the eye patched, for how long, and an estimate of the results.
Has there been any surgery?
If yes, estimate the results:
Please describe any visual therapy, including duration of treatment, age at which it was started and estimate the results:
Brain Injury
(Stroke, Head injury, Concussion, Whiplash, Motor Vehicle Accident, Bike Accident, Brain Surgery, etc...)
Date of most recent event:
Briefly describe the injury:
What part of the head was affected:
Face
Top of head
Back of head
Left side
Right side
Forehead
Was there loss of consciousness? For how long?
When did you first see a doctor regarding your accident/injury?
Where you hospitalized?
Describe any previous injuries and dates:
WHAT TYPES OF PROFESSIONAL CARE HAVE YOU RECEIVED OR ARE RECEIVING DUE TO THIS INJURY?
(List care such as neurological, psychological, occupational therapy, physical therapy, speech, auditory, chiro, osteopathic, acupuncture, neurofeedback)
What is your most significant visual concern at this time?
####### B I V S S ######### (Brain Injury Vision Symptom Survey) #############################################################
Score each behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4
EYESIGHT CLARITY
VISUAL COMFORT
DOUBLING
LIGHT SENSITIVITY
DRY EYES
DEPTH PERCEPTION
PERIPHERAL VISION
READING
If you experience any of the symptoms below, please check if the symptom was present before the injury, only after or both.
What activities can you no longer engage in due to your accident / injury?
Reading/Computer
CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)
Please answer the following questions about how your eyes feel when reading or doing close work.
NOTE: If the patient is a child, please read the instructions and then each item exactly as written.
If the patient responds with "yes" please qualify with frequency choices. Do not give examples.
Points: Never =0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4
NOTE: For children a score of 16 or more indicates the need for a binocular vision evaluation. For adults a score of 21 does.
In addition:
Check all that apply:
Dizziness/Motion Sensitivity
(Dizziness, Motion Sickness, Car Sickness, etc)
Check all of the symptoms that are significant for you:
Nausea, headache, or dizziness when reading in the car even on a STRAIGHT road
Nausea, headache, or dizziness when sitting close to a movie screen or watching a train go by
Hyper-sensitive to light (store lights seem bright, tend to wear sunglasses even on cloudy days)
Frequent, sometimes daily headache or "pressure" in your head
Nausea, headache, dizziness, or spacey feeling when shopping or moving through crowds of people
Unusual fear of heights
Lose your place easily when reading
Flickering lights bother you (light through trees when driving, or fluorescents)
Avoidance of driving because of car sickness