Demographics
Reason for Visit
What is the reason for YOUR visit: | |
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Are there any other concerns about your vision that are bothering you?: |
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Medical History
Do you have a family history of:
Do you have any family history of:
Please fill out the fields below if the patient is a child.
Lazy Eye
-----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:
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
-----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, 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?