Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Primary Doctor Misc/Guardian
  Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Reason for Visit

Reason for Visit
What is the reason for YOUR visit:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:

Are there any other concerns about your vision that are bothering you?:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:

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: Doctor:

Family Ocular History
Glaucoma: Cataracts: Crossed/Lazy:
Macular Degeneration: Retinal Detachment: Blindness:
Color Blindness: Nystagmus

Do you currently wear: None Over The Counter Glasses Glasses Contact lenses Both
Do you have backup glasses?
Do you want new glasses?

What's your current brand of contact lenses?: Cleaner:


Demographic Information
Race:
Ethnicity:
Preferred Language:

Medical History

Patient Medical History
Primary Care Physician: Last Visit: Reason For Visit:
Who may we thank for referring you?

List any injuries, surgeries, or hospitalizations the patient has had:
Pregnant Or Nursing:
Do you have any history of concussions?:Yes No    How long ago?:

Has a neurological evaluation been performed? If so by whom?
Results/Recomendations:

Family Medical History

Do you have a family history of:


Do you have any family history of:
Dyslexia: Learning disability: ADD/ADHD


Social History
Occupation: Hobbies:Computer Usage


Smoking Status: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long:
STD:

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

Grade: School: Grade repeated:


Review of Systems
ALLERGIC:
BLOOD/LYMPH:
CARDIOVASCULAR:
CONSTITUTIONAL:
EAR, NOSE, THROAT, HEAD:
ENDORCRINE:
GASTROINTESTINAL:
GENITOURINARY:
IMMUNOLOGIC:
INTEGUMENTARY:
MUSCULOSKELETAL:
NEUROLOGICAL:
PSYCHIATRIC:
RESPIRATORY:

Extended Case History


Please fill out the extended case history ONLY if you have been referred to our office OR
if you feel your child has a vision problem that could be affecting their school performance. Thank you!


Does your child report any of the following?
Headaches     Eyes tired
Blurred vision / focus goes in and out     Double vision
Words move around on the page     Eyes hurt
Motion sickness / car sickness     Dizziness

List any other complaints your child makes concerning his/her vision:

Does the patient experience any of the following?
Eyes frequently reddened       Squints frequently
Frequent eye rubbing       Frequent blinking
Bothered by light       Avoids reading
Closing or covering one eye       Tires easily
Head close to paper when reading/writing       Moves head when reading
Prefers being read to       Reverses letters or words
Confuses right and left       Skips, rereads or omits words
Confuses letters and numbers       Reads Slowly
Loses place while reading       Uses fingers as a marker
Vocalizes when reading silently       Poor reading comprehension
Comprehension decreases over time       Does not support paper when writing
Difficulty copying from the board       Poor word attack skills
Short attention span / loses interest       Difficulty with scissors / small hand tools
Remembers better what hears then sees       Seems to know material, but does poorly on test
Responds better orally then by writing       Difficulty with memory on a different page
Poor large motor coordination / clumsy       Frequent erasures
Sloppy handwriting       Writes neatly but slowly
Dislikes avoids near tasks       Dislikes / avoids sports
Difficulty catching / hitting a ball       Misaligns numbers or columns
Frustrated with homework/schoolwork


Is there a particular time when most of these symptoms are noticed?

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?
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: ______________________________________________________________________________________________________________________________________________________

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     Gastrointestinal 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: 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
Sits w/out support 6.5 months
Walks unaided / alone 12 months
Kicks a ball 18 months
Toilet trained 24 months
Rides tricycle 3 years

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

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

How is your child performing compared to others his/her age:
How well developed is your child's spoken vocabulary?

Has your child undergone any of the following testing/treatment/therapy?
Educational:YesNo Neurological:YesNo Psychological:YesNo
Occupational:YesNo Speech / Auditory:YesNo Physical:YesNo

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:
Reason for examination:
Were glasses, contact lenses or other optical devices recommended? If yes, are they used? 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? 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? 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 / Hay fever 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:

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.
BeforeAfter
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
BeforeAfter
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 up in the morning Dry Mouth
Eye lids swollen or red along the lash margin Night 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 cover 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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