Crystal PM Patient Forms

Demographics

Title	First	Last	MI	Suffix	Nickname	Pronoun

Address:
City:		State/ZipCode:

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
Email:
Birthday:		Occupation:
Sex:	Male Female	Employment Status:	Employed Full-Time Student Part-Time Student
Marital Status:		Employer/School Name:
Misc/Guardian:

Billing Information If the Billing Address is the SAME, check here:
If the Billing Address is DIFFERENT, please complete the following:

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Child History

Your Child's Profile
Mother/Caretaker's Name:
DOB: Occupation:
Employer: Bus. Phone:
Business Address:
Father/Caretaker's Name:
DOB: Occupation:
Employer: Bus. Phone:
Business Address:

Please list any siblings that the child has:

Name:		Birthday:
Name:		Birthday:
Name:		Birthday:

Name:		Birthday:
Name:		Birthday:

Referral Information

How did you hear about us?
If you were referred to our office, by whom?
Phone:	Address:
City:	State: Zip:

Visual History

Has there been a recent vision exam?		Name of Eye Doctor:		Date:
Results and Recommendations:

Are glasses or contacts worn? If so, how often?

If no, why not?

What is the main reason for today's vision exam?

How long has this problem/difficulty been observed?

*Have the following vision problems been diagnosed?*
Amblyopia (lazy eye)?		When diagnosed?
List any treatment or therapy for this condition (past or present)?

Strabismus (eye turn)?		When diagnosed?
List any treatment or therapy for this condition (past or present)?

Vision Symptom Survey

PLEASE COMPLETE ALL questions, and ask the child when appropriate Please rank each of the following symptoms with a number value 0 -4 0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always
Blurred vision at near		Misaligns digits in columns of numbers
Double vision		Poor handwriting, writing uphill or downhill
Headaches associated with near work		Reading comprehension declines over time
Painful, sore, or watery eyes		Holds reading material too close
Gets tired when reading		Difficulty reading for as long as expected/desired
Vision worse at the end of the day		Short attention span
Words run together when reading or move on the page		Difficulty completing assignments in reasonable time
Skipping or repeating lines when reading		Inconsistent or poor sports performance
Omitting small words when reading		Avoiding sports and games
Avoidance of reading or near work		Poor sense of space, knocks things over, clumsy
Dizziness or nausea associated with near work		Car sickness or motion sickness
Head tilted or turned		Closing one eye when reading
Difficulty copying from chalkboard		Reversal of letters like b's, d's, p's, and q's
List any other vision related concerns:

Academic Information

School:

Current Grade:

Teacher:

Has a grade been repeated? If so, which grade:

Why?

Does your child generally like school?		Any difficulty completing homework assignments?
Is assisstance required to complete homework?
Specifically describe any school difficulties:

Any special tutoring and/or remedial assistance?

If yes, when?

How long?

Describe the type and frequency of assistance:

Does your child like reading?		Does your child read for pleasure?
What does your child like to read?		What grade level does your child read at?
What is your child's attitude toward school?

How does your child perform in the following subject ares:
Reading		Social Studies/History
Writing		Art
Science		Other
Math		Other
Favorite subject:		Least favorite subject:
Overall academic performance is:		Is a great deal of effort spent to maintain this level of performance?
Do you feel achievement is up to potential?		Does/Do the teacher(s) feel achievement is up to potential?
Other Comments about academic performance:

Medical History

Primary Care Doctor's Name:	Address:
City: State:	Zip Code:
Is your child especially afraid of doctors?
Would you like a report sent to this doctor?

Medications: (including any vitamins and supplements)
For what condition(s)?

Medication Allergies:	Reaction:	Current state of health:

List any significant illnesses, head injury, surgical procedures, etc.:	Age	Severity	Complications




Any chronic health problems like asthma, hay fever, allergies, etc.
If yes, please explain:

Does your child have problems now or previously in the following areas:		No to all
Cancer:	If so, please explain:
Weight loss/gain:	If so, please explain:
Skin:	If so, please explain:
Allergies:	If so, please explain:
Neurological:	If so, please explain:
Ear/Nose/Throat:	If so, please explain:
Psychological:	If so, please explain:
Endocrine/Hormone:	If so, please explain:
Diabetes:	If so, what type:	When was it diagnosed:
Heart or Vascular:	If so, please explain:
Blood:	If so, please explain:
Gastrointestinal:	If so, please explain:
Kidney:	If so, please explain:
Bladder:	If so, please explain:
Muscle pain:	If so, please explain:
Joint pain:	If so, please explain:
Autoimmune disease:	If so, please explain:
Other:	If so, please explain:
Other:	If so, please explain:

Family History

Has anyone in the immediate family had or currently have any problems in the following areas:

Diabetes:		If so, who?
Heart disease:		If so, who?
High blood pressure:		If so, who?
Kidney disease:		If so, who?
Thyroid disease:		If so, who?
Cancer:		If so, who?
Rheumatoid arthritis:		If so, who?

Blindness:		If so, who?
Macular Degeneration:		If so, who?
Strabismus (eye turn):		If so, who?
Amblyopia (lazy eye):		If so, who?
Glaucoma:		If so, who?
Retinal detachment:		If so, who?
Learning Disability:		If so, who?

Other:

Special Testing

Has a neurological evaluation been performed?
If so, by whom?
Results and Recommendations:

Has a psychological evaluation been performed?
If so, by whom?
Results and Recommendations:

Has a occupational therapy evaluation been performed?
If so, by whom?
Results and Recommendations:

Has a physical therapy evaluation been performed?
If so, by whom?
Results and Recommendations:

Has a speech/hearing evaluation been performed?
If so, by whom?
Results and Recommendations:

Has an educational testing been performed?
If so, by whom?
Results and Recommendations:

Nutritional Information Are there any food allergies / sensitivities?
Describe:
Is a special diet in place?
Previous dietary treatments/restrictions:
Are there any periods of very high energy? If so, when?
Are there periods of very low energy? If so, when?

Birth and Delivery Information Describe any complications during pregnancy (injury, fever, illness, smoking, use of alcohol, prescription drug use, malnutrition, etc.):
Length of Pregnancy: Type of delivery:
Describe any complications during birth (vacuum, forceps, pitocin, oxygen deprivation, use of oxygen):
Child's birth weight:
Apgar score @ birth after 10 min

Developmental History Were there ever any concerns related to growth or development?

At what age did your child reach the following skills/milestones:

Creep (stomach on floor)?
Crawl (on all fours)?
Sit up (without support)?
Walk (without support)?
First words?

Describe any speech concerns:

Did your child have difficulty learning to ride a tricycle or bicycle?
Did your child have difficulty learning to run or skip?
Did your child have difficulty learning to tie shoes or button clothes?
Is your child generally well coordinated or clumsy?

Leisure Time Activities

Does your child watch television? If so, how many hours per day?
Does your child play computer/video games? If so, how many hours per day?
How many hours does your child spend outside each day?

Which sports does your child play?	Performance in each?	Do your child wish to do better? If so, describe.




What other activities/hobbies does your child enjoy?

Are there activities your child would like to participate in, but doesn't?

General Behavior Are there any behavior problems at home?
Are there any behavior problems at school?
What is your child's reaction to fatigue?
Does your child say and/or do things impulsively?
Does your child have difficulty sitting for tasks? Please describe:
Does your child SEEK vestibular or sensory inputs? Please describe:
Does your child AVOID vestibular or sensory inputs? Please describe:

Family and Home Life Please indicate which adult(s) child lives with (check all that apply):

Mother	Stepmother	Grandmother	Aunt	Foster Parents
Father	Stepfather	Grandfather	Uncle	Adoptive Parents
Other (please specifiy):

Has your child ever been through a traumatic family situation (such as divorce, parental loss, separation, severe parental illness)?
What was the situation?
What age was your child?
Is family life stable at this time? If not, please explain?
Do any immediate family members have a learning problem? If so, please explain?

Give a brief description of your child as a person:

Is there any other information that you feel would be helpful/important for the doctor to know?

Adult History

Please answer the following about YOURSELF:

Current Occupation:
Current Employer:
Number of work hours per week:
Other comments about work:

Please answer the following about your SPOUSE or SIGNIFICANT OTHER:

Spouse/Significant Other's Name:
DOB: Occupation:
Employer: Bus. Phone:
Business Address:

Please list any dependents or children:

Name:		Birthday:
Name:		Birthday:
Name:		Birthday:

Name:		Birthday:
Name:		Birthday:

Referral Information

How did you hear about us?
If you were referred to our office, by whom?
Phone:	Address:
City:	State: Zip:

Please list any individuals who you would like a report sent (include name and address):

Visual History

Has there been a recent vision exam?
Name of Eye Doctor:		Date:
Results and Recommendations:

Are glasses or contacts worn? If so, how often?

If no, why not?

What is the main reason for today's vision exam?

How long has this problem/difficulty been observed?

*Have the following vision problems been diagnosed?*
Amblyopia (lazy eye)?		When diagnosed?
List any treatment or therapy for this condition (past or present)?

Strabismus (eye turn)?		When diagnosed?
List any treatment or therapy for this condition (past or present)?

Vision Problems

Please rank each of the following symptoms with a number value 0 -4 0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always
Eye strain or pain		Uncomfortable while driving/riding in the car
Eye fatigue or eye rubbing		Difficulty adjusting focus between near and far
Blurry vision at near or far distances		Head tilt or unsteady gait
Double vision		Closing one eye
Headache after visual task		Skipping words or lines while reading
Dizziness or nausea after visual task		Cannot read for as long as you would like
Light sensitivity		Poor reading comprehension or slow reading speed
Poor depth perception		Poor memory
Bumps into objects/clumsiness		Decreased ability to participate in hobbies/sports
Can't tolerate visually-busy places
List any other vision related concerns:

Education/Employment Information

Current Status:

Full Time Student

Part Time Student

Full Time Employment

Part Time Employment

Retired

How many hours a day do you use a computer in your work, school, or leisure activities each day?
How many hours do you read printed material each day?
Do you wear glasses or contacts while at the computer?
How do your eyes feel after working at the computer?
Please list any tasks you find challenging in your current situation:

Please answer the following if you are in an academic program:
School: Current Grade:
Area of study:

Any special tutoring and/or remedial assistance?

How long?

Describe the type and frequency of assistance:

Overall academic performance is:		Is a great deal of effort spent to maintain this level of performance?
Do you feel achievement is up to potential?		Does/Do the teacher(s) feel achievement is up to potential?
Other Comments about Academic Performance:

Medical History

Primary Care Doctor's Name:	Address:
City: State:	Zip Code:

Medications: (including any vitamins and supplements)	For what condition(s)?

Medication Allergies:	Reaction:	Current state of health:

List any significant illnesses, head injury, surgical procedures, etc.:	Age	Severity	Complications




Any chronic health problems like asthma, hay fever, allergies, etc.
If yes, please explain:

Do you have problems now or previously in the following areas:
Cancer:		If so, please explain:
Weight loss/gain:		If so, please explain:
Skin:		If so, please explain:
Allergies:		If so, please explain:
Neurological:		If so, please explain:
Ear/Nose/Throat:		If so, please explain:
Psychological:		If so, please explain:
Endocrine/Hormone:		If so, please explain:
Diabetes:		If so, what type: When was it diagnosed:
Heart or Vascular:		If so, please explain:
Blood:		If so, please explain:
Gastrointestinal:		If so, please explain:
Kidney:		If so, please explain:
Bladder:		If so, please explain:
Muscle pain:		If so, please explain:
Joint pain:		If so, please explain:
Autoimmune disease:		If so, please explain:
Other:		If so, please explain:
Other:		If so, please explain:

Family History

Has anyone in the immediate family had or currently have any problems in the following areas:

Diabetes:		If so, who?
Heart disease:		If so, who?
High blood pressure:		If so, who?
Kidney disease:		If so, who?
Thyroid disease:		If so, who?
Cancer:		If so, who?
Rheumatoid arthritis:		If so, who?

Blindness:		If so, who?
Macular Degeneration:		If so, who?
Strabismus (eye turn):		If so, who?
Amblyopia (lazy eye):		If so, who?
Glaucoma:		If so, who?
Retinal detachment:		If so, who?
Learning Disability:		If so, who?

Other:

Special Testing

Has a neurological evaluation been performed?
If so, by whom?
Results and Recommendations:

Has a psychological evaluation been performed?
If so, by whom?
Results and Recommendations:

Has a physical therapy evaluation been performed?
If so, by whom?
Results and Recommendations:

Has a speech/hearing evaluation been performed?
If so, by whom?
Results and Recommendations:

Has an educational testing been performed?
If so, by whom?
Results and Recommendations:

Leisure Time Activities

Do you like to read?

Do you read for pleasure?

What do you like to read?

List any hobbies or sports	Performance in each?	Do you wish to do better? If so, describe.




Other hobbies or sports:
Are there activities you would like to participate in, but don't?

Give a brief description of yourself as a person:

Is there any other information that you feel would be helpful/important for the doctor to know?

Submit Data

Please check the boxes below to acknowledge that you have read and understand the following office policies:

By checking here I hereby give my permission to DENVER VISION THERAPY, PC to treat above named Patient and I also accept any and all financial responsibilities for services provided.

By checking here I acknowledge that payment is due at the time of service. We are not in network with any insurance companies and do not submit directly to insurance. We are happy to print out itemized invoices with procedure and diagnostic codes if you choose to submit for reimbursement on your own.

I acknowledge that the Notice of Privacy Practices is available at the office location where treatment is conducted and that I have read and understood the notice. I further acknowledge that I have the right to request a copy of the notice and one will be provided.

Cancellation Policy for Vision Therapy Evaluations (new patient exams): If you must cancel or reschedule your vision therapy evaluation, we request at least 48 hours of notice. If an appointment is cancelled with less than 48 hours notice, or if the patient no-shows more than twice, a 50% deposit will be required before another appointment can be scheduled.

New Patient Form

Please complete the Child History tab if the patient is a child (17 or younger), and the Adult History tab if the patient is an adult (18 or older). ALL PATIENTS should complete the Demographics tab. When finished, submit the data on the Submit Data tab.

Demographics

Child History

Adult History

Submit Data

After completing all forms, please submit data on the final tab.