Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	FL AK AL AR AZ CA CO CT DC DE GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV 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. Shim, Debra	Misc/Guardian
		Primary Care Doctor	Dreifuss, MS OTR/L ,Camy Forgan, PH.D. , Jim Grant, Au.D. , Mel Hance, OTR/L , Marcia Keith, OTR/L, Beth Kelderman, Ph.D., Jill Light, Au.D , Leah Otero, MD , Elizabeth Robyn Turk, MS, OTR/L Victoria Knopp,OT Weiner, Au.D. ,Aimee l.

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

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

Home Phone:
Work Phone:

Reason for Visit

Reason for Visit

What is the reason for YOUR visit:

Location:	Both eyes Right eye Left eye RUL RLL LUL LLL temporal frontal top of head back of head behind eyes Other	Severity:	Mild Moderate Severe Other	Quality:	constant getting worse pressure stabbing throbbing getting better unchanged Other	Duration:	ongoing 1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year Other
Timing:	after school AM constant during classes fluctuates increases throughout day PM Other	Context:	computer cycle driving fishing gardening golfing needlepoint/crochetting outdoor sports outdoors playing with kids random reading school tv water sports Other	Modifying:	artificial tears help compresses help contacts help glasses help no help OTC drops help OTC medication helps resting/ closing eyes help RX medication/drops help sleep helps Other	Associated:	allergies blurred vision Contacts discharge dizzy double vision eye pain glasses h/o previous head trauma h/o previous ocular trauma headache light sensitive loss of vision Medications stress thick discharge trauma watery discharge Other

Are there any other concerns about your vision that are bothering you?:

Location:	Both eyes Right eye Left eye RUL RLL LUL LLL temporal frontal top of head back of head behind eyes Other	Severity:	Mild Moderate Severe Other	Quality:	constant getting worse pressure stabbing throbbing getting better unchanged Other	Duration:	ongoing 1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year Other
Timing:	after school AM constant during classes fluctuates increases throughout day PM Other	Context:	computer cycle driving fishing gardening golfing needlepoint/crochetting outdoor sports outdoors playing with kids random reading school tv water sports Other	Modifying:	artificial tears help compresses help contacts help glasses help no help OTC drops help OTC medication helps resting/ closing eyes help RX medication/drops help sleep helps Other	Associated:	allergies blurred vision Contacts discharge dizzy double vision eye pain glasses h/o previous head trauma h/o previous ocular trauma headache light sensitive loss of vision Medications stress thick discharge trauma watery discharge Other

Notes:

Review of Ocular System

List any eye disease or eye trauma you've had or are currently experiencing:
List any eye surgeries that you've had:
Eye Meds:

Last Eye Exam:

1 year 2 years > 3 years Other

Doctor:

Dr. Shim Dr. Allen Dr. Brockman Dr. Gallogly Dr. Kelso Dr. Lavina Dr. Leal Dr. Michaels Dr. Nelson Dr. Ramsey Dr. Rubin Dr. Skolnick Other

Family Ocular History

Glaucoma:	No Brother Father MAunt MGF MGM MUncle Mother PAunt PGF PGM PUncle Sister Other	Cataracts:	No Brother Father MGF MGM Mother PGF PGM Sister Other	Crossed/Lazy:	No Brother Father MAunt MGF MGM MUncle Mother PAunt PGF PGM PUncle Sister Other
Macular Degeneration:	No Brother Father MAunt MGF MGM MUncle Mother PAunt PGF PGM PUncle Sister Other	Retinal Detachment:	No Brother Father MAunt MGF MGM MUncle Mother PAunt PGF PGM PUncle Sister Other	Blindness:	No Brother Father MAunt MGF MGM MUncle Mother PAunt PGF PGM PUncle Sister Other
Color Blindness:	No Brother Father MAunt MGF MGM MUncle Mother PAunt PGF PGM PUncle Sister Other	Nystagmus	No Brother Father MAunt MGF MGM MUncle Mother PAunt PGF PGM PUncle Sister Other

Do you currently wear:	None Over The Counter Glasses Glasses Contact lenses Both
Do you have backup glasses?	No Yes Other
Do you want new glasses?	Yes No Other

What's your current brand of contact lenses?:

None Soft Colored PMMA RGP Other

Cleaner:

Biotrue Boston Advance Boston Complete Boston Simplus Clear Care Clear Care Plus Equate Generic none Optifree Express Optifree PureMoist Optifree Replenish Renu Other

Demographic Information

Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Preferred Language:	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Medical History

Patient Medical History

Primary Care Physician:

Doesn't Remember Dr. Ada Hanlon Dr. Alfred Dosdos Dr. Bruce Barnville Dr. Frank Delucia Dr. Gabriella Bonomo Dr. Kathyn Renolds Dr. Larry Cohen Dr. Lorne Stitsky Dr. Lynda Bideau Dr. Orlan Carr III Dr. Paul Abreu Dr. Shital Patel Dr. Stephen Adler Infants & Children None Pediatric Assoc Pediatric Partners Premier Medical Care Of the PB Primary Care Partners Other

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

Who may we thank for referring you?

Unknown Meds:

List any injuries, surgeries, or hospitalizations the patient has had:

Pregnant Or Nursing:

No Yes Unsure Other

Do you have any history of concussions?:

Yes No

How long ago?:

N/A < 5 years 5-10 years > 10 years Other

If yes please explain:

Any history of?

Dyslexia

Learning disabilities

ADD/ADHD

Has a neurological evaluation been performed?

Yes No Other

If so by whom?

Results/Recomendations:

Family Medical History

Do you have a family history of:

None Adopted/unknown Athritis Cancer Cardiovascular Disease Diabetes HTN Kidney Disease Lupus Thyroid ADD/ADHD Other

ADD/ADHD Arthritis Cancer Cardiovascular Diabetes HTN Kidney Lupus Thyroid Thyroid Other

ADD/ADHD cancer cardiovascular diabeties thyroid Other

cancer cardiovascular diabeties thyroid shingles Other

Do you have any family history of:

Dyslexia:

Learning disability:

ADD/ADHD

Social History

Occupation:

Hobbies:

Computer Usage

> 2 hours per day 2-4 hrs per day 4-6 hrs per day 8-10 hrs per day 10+ hrs per day Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Chewing Tobacco Cigar Cigarrettes Vapor Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Please fill out the fields below if the patient is a child.

Grade:

School:

Grade repeated:

Review of Systems

ALLERGIC:	None animal dander/fur dust gluten latex mold peanuts/nuts pollens seasonal shellfish Other
BLOOD/LYMPH:	None Anemia Coagulation Disorder Leukemia Lymphoma Breast Carinoma Hematologic Disorder Hodgkin's Dz Sickle Cell Dz Temporal Arteritis Varicose Veins Other
CARDIOVASCULAR:	None AFIB Aneurysm Angina Arrhythmia Arteriosclerosis Cardiovascular Dz Coagulation Disorder Congestive Heart Dz Elevated Cholesterol Endocarditis Heart Murmur Heart Surgery HTN HTN borderline Mitral Valve Prolaps Myocardia Infarction Stroke Other
CONSTITUTIONAL:	None Anemia Appetite (Excess) Appetite (Loss) Blackouts Car sickness Chills Colds Constipation Coughing Cramps Disorientation Dizziness Fainting Fatigue Fever Growth (Excess) Nausea Night Sweats Nosebleeds Sleep (Irregular) Sweating Thirst (Excess) Urination (Excess) Vomiting Weakness Weight Gain Weight Loss Other
EAR, NOSE, THROAT, HEAD:	None Chronic Cough Cluster HA's Deviated Septum Dry Throat / Mouth Ear Infections Encephalitis Headaches Hearing impaired Hearing Loss Meniere's Syndrome Migrain HA's Ringing Ears Seizures Sinusitis Trauma Other
ENDORCRINE:	None Cholesterol Elevated Crohn's Dz Diabetes Type 1 Diabetes Type 2 Diabetic Suspect Gout Hyperthoyroid Hypothyroid Hypoglycemia Pituitary Disorder Renal Dz Impotence Other
GASTROINTESTINAL:	None Acid Reflux Alcoholism Anorexia Cirrhosis Colitis Colon Cancer Constipation Diarrhea Diverticulosis Gall Bladder Gall Stones Hepititis Hiatus Hernia IBS Intestinal Obstruction Jaundice Liver Cancer Ulcer Other
GENITOURINARY:	None Amenorrhea Bladder Infections Ectopic Pregnancy Impotence Incontinence Kidney Stones Menopause Ovarian Cyst Pelvic Inflammatory Dz Prostate Disorder Prostate Cancer Sexually Transmitted Syphilis Uterine Cancer Other
IMMUNOLOGIC:	None AIDS Herpes Simplex Herpes Zoster Histoplasmosis HIV Positive Molluscum Contagiosum MRSA Rheumatic Fever Sjogren's Syndrome Staphylococcus Infection Streptococcus Infection Syphilis TB --- Onset, Recently last few months within last year 1 year 2 years 3-5 years > 5 years ---Quality, Getting better Remaining stable Getting worse ---Medication, Currently No medication Other
INTEGUMENTARY:	None Acne Acne Rosacea Albinism Atopic Dermatitis Contact Dermatitis Dermatitis Dry Skin Eczema Impetigo Lupus Raynaud's Dz Vitiligo Xeroderma Other
MUSCULOSKELETAL:	None Arthritis Down's Syndrome Joint Pain Marfan's Syndrome Muscular Dystrophy Myasthenia Gravis Polymalgia Rheumatica Scoliosis Stiffness Other
NEUROLOGICAL:	None Bell's Palsy Brain Damage Brain Tumor Cerebral Palsy Cluster HA Dyslexia Encephalitis Epilepsy Fibromyalga Headache Migraine HA migraines Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Numbness nystagmus Nystagmus Paralysis Parkinsons Seizure Disorder Spinal Cord Trauma Stroke Vertigo Other
PSYCHIATRIC:	None anxiety depression insomnia ADD ADHD bi polar dementia alzheimer's autism mentally challenged Other
RESPIRATORY:	None Asthma Asthma, exercise induced Bronchitis COPD Cystic Fibrosis Emphysema Lung Cancer Lung Dz Pneumonia Sarcoidosis Tuberculosis Other

Child History

***PLEASE FILL OUT THE CHILD HISTORY FORM IN FULL

-----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/Condition...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: ______________________________________________________________________________________________________________________________________________________

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 birth weight:lbs. and oz.
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:
If referred do you agree with the reason for the referral?
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"		Eye turns in / out		Head tilt / Face turn
	Eyelid Droops		Frequent styes		Eyes frequently reddended
	Bothered by light		Motion Sickness / Car Sickness		Loses attention easily
	Frequent blinking		Squints frequently		Frequent eye rubbing
	closing or covering one eye		Tires easily		Lacks interest in looking at objects
	Nausea when doing visual tasks		poor tracking / eye movements		Confuses right and left
	Confuses letters and numbers		Reverses letters or words		Misaligns number or columns
	Frequent erasures		Head close to paper when readin/writing		Looses place while reading
	Moves head when reading		Vocalizes when reading silently		Reads slowly
	Avoids reading		Prefers being read to		Comprehension decreases over time
	Dislikes avoids near tasks		Responds better orally then by writing		Difficulty copying from the board
	Remembers better what hears then sees		Trouble with following sequence of directions		Sloppy handwriting
	Skips, rereads or omits words		Uses fingers as a marker		Poor reading comprehention
	Does not support paper when writing		Poor word attack skills		Difficulty with scissors / small hand tools
	Difficulty with memory on a different page		Seems to know material, but does poorly on test		Writes neat but slowly
	Frustrated w/ Homework / Schoolwork		Dislikes / avoids sports		Difficulty catching / hitting a ball
	Poor large motor coordination / clumsy		Short Attention span / loses interest		When reading, letters / words appear to move or float around

Are there any other complaints your child makes concerning vision?

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


______________________________________________________________________________________________________________________________________________________

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:

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:

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

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 driving at night

VISUAL COMFORT

Eye discomfort / sore eyes / eyestrain
Headaches 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?

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