New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Ms.

Address:
City:		State/ZipCode	OR AK AZ CA CO CT FL GA HI ID IL IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Marshall, Gabby Dr. Balsalobre, Amanda	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Ms.

Address

City	State	ZipCode
	OR AK AZ CA CO CT FL GA HI ID IL IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Child History

-----SECTION 1------PEDIATRIC EYE HEALTH HISTORY------PLEASE COMPLETE FOR YOUR CHILD------------------------------------------------------------------

Child's Full Name:

Child's Preferred Name:

Mother/Caretaker's Name:		Occupation:		Bus. Phone:
Father/Caretaker's Name:		Occupation:		Bus. Phone:

______________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY:

Pediatrician's Name: Is your child especially afraid of Doctors: YesNo
Last Visit Date: For What Reason? Is your child generally healthy? yes no
Medications (including vitamins & supplements):
Allergies to Medications:
______________________________________________________________________________________________________________________________________________________

List significant illnesses, bad falls, high fevers or chronic illnesses:
Event/Condition...Age...Severity...Complications:
Event/Conditions...Age...Severity...Complications:
______________________________________________________________________________________________________________________________________________________

Neuro/psych eval: YesNo By Whom?
Occupational Therapy eval? YesNo By Whom?
______________________________________________________________________________________________________________________________________________________

Poor Vision:	Child	Family					If Family, who?
Strabismus:	Child	Family					If Family, who?
Amblyopia:	Child	Family					If Family, who?
Cancer:	Child	Family					If Family, who?
Epilepsy/Seizures:	Child	Family					If Family, who?
Learning issue:	Child	Family					If Family, who?
Blindness:	Child	Family					If Family, who?

Other: ______________________________________________________________________________________________________________________________________________________

MED HX / SYSTEM REVIEW:

NOTICE OR COMPLAINS OF:						DOES CHILD HAVE OR HAD:
Eye turns in / out:	Yes	No***				Eye injury or surgery:	Yes	No***
Squints / Blinks a lot:	Yes	No				Lazy eye / Amblyopia:	Yes	No***
Covers / Closes one eye:	Yes	No				Patching:	Yes	No***
Lacks interest in looking at objects:	Yes	No***				Vision Therapy / Orthoptics:	Yes	No***
Rubs eyes excessively:	Yes	No				Surgery / Hospitalizations:	Yes	No
Reddened or encrusted eyelids:	Yes	No				Breathing problems:	Yes	No
Eyelid Droops:	Yes	No				Gastointestinal problems:	Yes	No
Poor tracking / eye movements:	Yes	No				Musculoskeletal problems:	Yes	No
Head tilt / Face turn:	Yes	No				Neurological problems:	Yes	No
Stumbles over objects / clumsy:	Yes	No				Development delayed:	Yes	No
Poor motor control:	Yes	No				Ear / Nose / Throat problems:	Yes	No
Head injury / trauma:	Yes	No

*** If yes, please complete strabismus / amblyopia tab.

______________________________________________________________________________________________________________________________________________________
DEVELOPMENTAL HISTORY:

Length of Pregnancy: Type of delivery: Natural Caesarian Forceps / Vacuum Anesthesia

During pregnancy of this child, did any of the following occur:

toxemia	trauma	use of alcohol
injury by fall	smoking	use of drugs
severe illness	prescription medication	little obstetrical care
other

Please explain:

Child's birthweight:lbs. and ozs.
Apgar score:@ birth after 10 minutes
My child is:
biological
adopted      At what age?
foster
other      Explain:

______________________________________________________________________________________________________________________________________________________
SKILLS / MILESTONES:

GROSS MOTOR
ACTIVITY	AVERAGE AGE	YOUR CHILD
Rolled over	3.5 months	Early Late Normal Unsure
Sits w/out support	6.5 months	Early Late Normal Unsure
Walks unaided / alone	12 months	Early Late Normal Unsure
Kicks a ball	18 months	Early Late Normal Unsure
Toilet trained	24 months	Early Late Normal Unsure
Rides tricycle	3 years	Early Late Normal Unsure

FINE MOTOR
ACTIVITY	AVERAGE AGE	YOUR CHILD
Reaches / grasp for object	4 months	Early Late Normal Unsure
Scribbles spontaneously	15 months	Early Late Normal Unsure
Stacks / Piles blocks	18 months	Early Late Normal Unsure
Eats with a fork/spoon	3 years	Early Late Normal Unsure

LANGUAGE
ACTIVITY	AVERAGE AGE	YOUR CHILD
Smiles spontaneously	1 month	Early Late Normal Unsure
Says single words	12 months	Early Late Normal Unsure
Refers to self by first name	18 months	Early Late Normal Unsure
Knows full name	3 years	Early Late Normal Unsure

How is your child performing compared to others his/her age: Above average Average Below average
How well developed is your child's spoken vocabulary? excellent very well developed average behind delayed

Has your child undergone any of the following testing/treatment/therapy?

Educational:	Yes	No	Neurological:	Yes	No	Psychological:	Yes	No
Occupational:	Yes	No	Speech / Auditory:	Yes	No	Physical:	Yes	No

If yes, please list all previous evaluations done on your child:


Current grade in school: School:
What is their favorite subject?

______________________________________________________________________________________________________________________________________________________
VISUAL HISTORY:

Main reason for having an examination today:
Date of last evaluation: Doctor's name: Gabby Marshall, OD Amanda Balsalobre, OD Michael Coffman, OD Audrey Brumley, OD
Reason for examination:
Were glasses, contact lenses or other optical devices recommended? Yes No If yes, are they used? Yes No Sometimes If yes, when?
If no, why not?
Results / Recommendations:

Do you observe or does your child report any of the following?

	Headaches		Blurred Vision
	Double Vision		Eyes "hurt" or "tired"
	Nausea when doing visual tasks		Motion Sickness / Car Sickness
	Bothered by light / sun light		Frequent styes
	Eyes itch		Eyes burn
	Eyes tear		Eyes frequently reddened
	Closing or covering one eye		Loses place while reading
	Poor reading comprehension		When reading, letters/words appear to move or float around
	Loses attention easily

Are there any other complaints your child makes concerning vision?

Do you have any other concerns / observations concerning your child's vision?


______________________________________________________________________________________________________________________________________________________

Were you referred to our office? Yes No Whom may we thank for this referral?
Referral address: Phone:
If not referred, how did you hear about us?

Strabismus/Amblyopia

-----SECTION 2-----STRABISMUS / AMBLYOPIA HISTORY ----------------------------------------------------------------------------------------------------

(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:

up	down
to the right	to the left
up close	in the distance

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? yes no If yes, estimate the results:

Please describe any visual therapy, including duration of treatment, age at which it was started and estimate the results:

Adult History

-----SECTION 3--------ADULT EYE HEALTH 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)?

	Blindness		Corneal Dystrophy		Thyroid Eye Disease		Cataract
	Eye / Eyelid Cancer		Macular Degeneration		Implant Lens Right Eye		Glaucoma
	Retinal Detachment		Implant Lens Left Eye		Hypertensive Retinal Disease		Diabetic Retinal Disease
	Dry Eye Syndrome		Amblyopia / Lazy Eye ** if yes, complete strabismus / amblyopia tab		Strabismus / Wandering Eye ** if yes, complete strabismus tab

Other Eye Conditions:

Check any of the following symptoms you experience:

	Eye Pain		Flashes of Light		Change in Distance Vision		Dryness or Burning in Eyes**
	Light Sensitivity		Change in Near Vision		New Spots or Floaters		Sandy or Gritty Feeling**
	Fluctuating Vision		Eye Itching		Excess Tearing
	Double Vision		Mucus Discharge or Crusted Lids		Loss of Side Vision		**If yes to above, complete dry eye tab

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?

	Allergy / Hayfever		Rheumatoid Arthritis		Herpes Zoster		Asthma		HIV		Skin Rashes
	Thyroid Disease		Hepatitis		Sinus Problems		Cancer		Headaches		Seizures
	Depression		Migraines		Multiple Sclerosis		High Blood Pressure		Diabetes (insulin dependent)		Parkinson's Disease
	Low Blood Pressure		Diabetes (non-insulin dependent)		Alzheimer's Disease		Head Injury (including Whiplash) - complete brain injury tab		High Cholesterol		Stroke

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?

	Glaucoma		Rheumatoid Arthritis		Diabetes
	Retinal Disease		Retinal Detachment		Crossed or Wandering Eye
	Macular Degeneration		Albinism		Amblyopia / Lazy Eye

Other Family History of Eye Conditions:

______________________________________________________________________________________________________________________________________________________

Were you referred to our office? Yes No Whom may we thank for this referral?
Referral address: Phone:
If not referred, how did you hear about us?

Brain Injury

-----SECTION 4--------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, audiitory, chiro, osteopathic, accupuncture, 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

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

VISUAL COMFORT

Eye discomfort / sore eyes / eyestrain
Headahces or dizziness after using eyes
Eye fatigue / very tired after using eyes all day
Feel "pulling" around eyes

DOUBLING

Double vision -- especially when tired
Have to close or cover one eye to see clearly
Print moves in and out of focus when reading

LIGHT SENSITIVITY

Normal indoor lighting is uncomfortable
Outdoor light too bright -- have to use sunglasses
Indoors fluorescent light is bothersome or annoying

DRY EYES

Eyes feel "dry" and sting
"Stare" into space without blinking
Have to rub the eyes a lot

DEPTH PERCEPTION

Clumsiness / misjudge where objects really are
Lack of confidence walking / missing steps / stumbling
Poor handwriting (spacing, size, legibility)

PERIPHERAL VISION

Side vision distorted / objects move or change position
What looks straight ahead -- isn't always straight ahead
Avoid crowds / can't tolerate "visually busy" places

READING

Short attention span / easily distracted when reading
Difficulty / slowness with reading and writing
Poor reading comprehension / can't remember what was read
Confusion of words / skip words when reading
Lose place / have to use finger not to lose place when reading

If you experience any of the symptoms below, please check if the symptom was present before the injury, only after or both.

Before	After
	Dizziness or motion sickness
	Dislike heights
	Difficulty understanding what is seen
	Difficulty using both sides of the body together
	Difficulty recognizing words
	Memory problems
	Difficulty recognizing faces
	Difficulty focusing one or both eyes
	Difficulty remembering names of objects
	Frequent squinting or blinking
	Difficulty remembering people's names
	Vision appears unstable or shifts from eye to eye
	Unusual head tilt or turn
	Difficulty with time management
	Portions of a page or objects appear to be missing

Before	After
	Difficulty finding objects when grouped together
	People or things suddenly appear unexpectedly from one side
	Patterned wallpaper or carpets are bothersome
	Awkward or poor balance
	Looking to the side of objects to see them better
	Ears ringing / Tinnitus
	Tunnel vision
	Confusion / Disorientation
	Difficulty concentrating on visual tasks
	Gets lost often
	Difficulty maintaining eye contact
	Bothered by noises
	One eye turns in, out, up or down
	Bothered by touch
	Flashes of light

What activities can you no longer engage in due to your accident / injury?

Dry Eye

----- SECTION 5 ------ DRY EYE HISTORY ---------------------------------------------------------------------------------------------------------------

Over the past week, which of the following eye symptoms have you experienced?

	Glare		Eye ache		Itching
	Redness		Burning		Light Sensitivity
	Tearing / Watery eyes		Stinging		Grittiness
	Dryness		Mattering on your eyelids when you wake iup in the morning		Dry Mouth
	Eye lids swollen or red along the lash margin		Nght Driving Problems		Burning in the morning
	Decreased contact lens wearing time		Vision fluctuates from clear to blurry especially in the morning, after reading, watching TV, computer use or driving.		Artificial Tear drops help but do not last long enough

Do you take Omega-3 supplements daily?
Do you use Visine or other "get the red out" drops? How often?
Have you ever been prescribed RESTASIS eye drops?

Reading/Computer

----- SECTION 6 ------ READING AND COMPUTER SYMPTOM CHECKLIST ----------------------------------------------------------------------------------------

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

1. Do your eyes feel tired when reading or doing close work?
2. Do your eyes feel uncomfortable when reading or doing close work?
3. Do you have headaches when reading or doing close work?
4. Do you feel sleepy when reading or doing close work?
5. Do you lose concentration when reading or doing close work?
6. Do you have trouble remembering what you have read?
7. Do you have double vision when reading or doing close work?
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
9. Do you feel like you read slowly?
10. Do your eyes ever hurt when reading or doing close work?
11. Do your eyes ever feel sore when reading or doing close work?
12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?
14. Do you lose your place when reading or doing close work?
15. Do you have to reread the same line of words when reading?

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:

	Reverses or forgets letters, numbers or words
	Tendency to close or sover one eye
	Confuses similar looking words
	Head tilt or movement
	Difficulty recognizing the same word in the next paragraph
	Poor reading comprehension
	Poor spelling
	Head too close to the paper while reading or writing
	Poor visual-motor (eye-hand/foot) coordination
	Difficulty tracking moving objects, balls, etc...

	Confuses right and left
	Writing is crooked or poorly spaced
	Difficulty following a sequence of directions
	Misalignment of digits or columns of numbers
	Whispers when reading silently
	Errors copying from chalkboard, computer or book
	Comprehension decreases over time
	Avoids near work or reading
	Does not visualize
	Difficulty completing assignments in the time allotted

Dizziness/Motion Sensitivity

----- SECTION 7 ----- DIZZINESS AND MOTION SENSITIVITY CHECKLIST -------------------------------------------------------------------------------------

(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

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