Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Age:
Cell Phone: Preferred Contact Method:
SSN Email
Date of Birth Occupation
Sex Male Female Employment Status Employed Full-Time Student
Part-Time Student
Marital Status Employer / School Name
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary Medical Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Date of Birth:
SSN:
Employer/School:

Secondary Medical Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary Medical Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History


THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY BOTH ADULT AND CHILDREN PATIENTS

Father's Name:
Mother's Name:

Family eye doctor: Last eye exam:
Dialation? YES NO     Optomap?YES NO
Did they prescribe?     Glasses Contact Lenses
Were you referred by your family eye doctor? YES NO
If not your family eye doctor, whom can we thank for referring you?
Contact information and address, if known:
Reason for exam today:

MEDICAL INFORMATION
Primary physician's Name:
Date of last exam:
Does your physician have any areas of concern regarding your health?
Please list any food, drug or seasonal allergies:
Please list any vaccine reactions or injuries:

Have you received any of the following examinations? Check any that apply and list the name of the provider.

Neuropsychological:Speech/Hearing Specialist:
Occupational Therapist:Other Specialist:
Results/Recommendations:

REVIEW OF SYSTEMS
Please mark EACH BOX Yes or No for the following. If Yes, please describe in the space provided:
YES NO   General Constitutional (unexplained fever, weight loss or gain, etc.)
YES NO   Eyes (Disease related such as Glaucoma, Detached Retina)
YES NO   Ears, Nose, Throat, Mouth (Hearing loss, chronic nasal congestion, chronic cough)
YES NO   Respiratory (Asthma, chronic bronchitis, shortness of breath, etc.)
YES NO   Cardiovascular (Diabetes, hypertension, heart problems, etc.)
YES NO   Gastrointestinal (Diarrhea, constipation, hernia, ulcers, etc.)
YES NO   Genitourinary (Painful urination, frequent urinations, jaundice, etc.)
YES NO   Hematological/Lymphatic (anemia, bleeding problems, etc.)
YES NO   Musculoskeletal (Muscle pain, trauma, osteoarthritis, osteoporosis, etc.)
YES NO   Skin (Eczema, Psoriasis, rashes, etc.)
YES NO   Neurological (Epilepsy, Cerebral Palsy, tumor, etc.)
YES NO   Psychiatric (ADHD, Depression, anxiety, etc.)
YES NO   Endocrine (Diabetes, Thyroid problems, etc.)
YES NO   Allergic/Immunological (Please list all food and environmental allergies)

MEDICATIONS
Please list any medications you are taking:
1.for 2.for
3.for 4.for

FAMILY HISTORY
Mark EACH BOX Yes or No and indicate which family member in the box provided. Family history includes your parents, grandparents, siblings and your children.
YES NO Blindness YES NO Cataract YES NO Macular Degeneration
YES NO Glaucoma YES NO Retinal Detachment YES NO Lupus
YES NO Heart Disease YES NO High Blood Pressure YES NO Thyroid Disease
YES NO Diabetes YES NO Cancer YES NO Dyslexia or reading problems
YESNOStrabismus (eye turn or crossed eyes)YESNOAmblyopia (lazy eye)Other:

DEVELOPMENTAL HISTORY (For Children)
Please answer the following and explain any noteable issues in the box provided.
Full term pregnancy? Caesarean or vaginal delivery?
Complications before/during/after delivery?
Did your child crawl? At what age?
At what age did they walk?
At what age were their first words? First sentences?
Age at beginning of kindergarten?
Age at beginning of 1st grade?
Delays in GROSS motor development (learning to crawl, walk, ride a bike, catch a ball)?
Delays in FINE motor development (tie shoes, draw/write, use scissors)?
Is your child performing up to their potential?
What is their current grade level?
What school do they attend?
Does your child like school? Why or why not?
Does your child like to read? Why or why not?
On what grade level does your child read?
Does you child experience any difficulties in school?
What subjects are easier?
What subjects are more difficult?
Has your child been retained?
Does test taking appear to cause anxiety?
Does your child receive tutoring or special assistance in school?
How does your child spend their free time?
How many hours daily do they: read? watch TV? play video games?use tablet/cell/computer? study?
Does their school consider your child to have a learning problem?
Does their school consider your child to have a discipline/behavior problem?
When fatigued, will your child: sag/slouchbecome irritablebecome excited other
Under tension, will your child exhibit: inattentiveness negativity defiance other
Have they been assessed for dyslexia? What were the results?
Have they been assessed for ADD/ADHD? What were the results?
Have they been professionally evaluated for any other concerns?
Is there any other information you feel would be helpful in your child's assessment?

SYMPTOMS
ACADEMIC
Skips words (especially small words) or lines when reading AlwaysFairly OftenSometimesInfrequentlyNever
Misses punctuation when reading Always Fairly Often Sometimes Infrequently Never
Substitutes words when reading or copying Always Fairly Often Sometimes Infrequently Never
Loses place when reading or doing close work Always Fairly Often Sometimes Infrequently Never
Has difficulty remembering what was just read Always Fairly Often Sometimes Infrequently Never
Uses finger or straight edge to follow what is being read Always Fairly Often Sometimes Infrequently Never
Tilts head or book when reading Always Fairly Often Sometimes Infrequently Never
Whispers or speaks aloud to self while reading Always Fairly Often Sometimes Infrequently Never
Has poor reading comprehension Always Fairly Often Sometimes Infrequently Never
Reads slowly or exhibits low "words per minute" in school Always Fairly Often Sometimes Infrequently Never
Has difficulty concentrating when reading or doing near work Always Fairly Often Sometimes Infrequently Never
Confuses words/letters/numbers Always Fairly Often Sometimes Infrequently Never
Reverses words/letters/numbers Always Fairly Often Sometimes Infrequently Never
Doesn't recognize words previoulsy/recently learned Always Fairly Often Sometimes Infrequently Never
Misaligns digits/words in columns/rows when writing Always Fairly Often Sometimes Infrequently Never
Reading comprehension declines over time Always Fairly Often Sometimes Infrequently Never
Says "I can't" before trying Always Fairly Often Sometimes Infrequently Never
Holds reading material or media too close Always Fairly Often Sometimes Infrequently Never
Writes incorrectly (uphill/downhill/improper letter formation) Always Fairly Often Infrequently Sometimes Never
Difficulty completing school assignments on time Always Fairly Often Sometimes Infrequently Never
Difficulty copying from board or textbook to paper Always Fairly Often Sometimes Infrequently Never
Difficulty with spelling Always Fairly Often Sometimes Infrequently Never
Difficulty with sequences or math processes Always Fairly Often Sometimes Infrequently Never
Has difficulty with money concepts, making change Always Fairly Often Sometimes Infrequently Never

BEHAVIORAL
Low self esteem Always Fairly Often Sometimes Infrequently Never
Unexplained poor or deteriorating behavior Always Fairly Often Sometimes Infrequently Never
Restless or fidgety when doing independent assignments/homework Always Fairly Often Sometimes Infrequently Never
Avoids tasks requiring concentration Always Fairly Often Sometimes Infrequently Never
Has poor memory, forgetfulness Always Fairly Often Sometimes Infrequently Never
Has a short attention span/difficulty holding attention Always Fairly Often Sometimes Infrequently Never
Exhibits obsessive or compulsive traits Always Fairly Often Sometimes Infrequently Never
Exhibits anxiety over usually normal situations Always Fairly Often Sometimes Infrequently Never
Misplaces or loses schoolwork, personal belongings Always Fairly Often Sometimes Infrequently Never
Difficulty with time management Always Fairly Often Sometimes Infrequently Never

VISUAL MOTOR
Accident prone Always Fairly Often Sometimes Infrequently Never
Poor coordination/balance Always Fairly Often Sometimes Infrequently Never
Tends to knock things down/over Always Fairly Often Sometimes Infrequently Never
Avoids/difficulty with activities requiring hand-eye coordination Always Fairly Often Sometimes Infrequently Never
Dislikes sports/physical activities Always Fairly Often Sometimes Infrequently Never
Difficulty estimating distance accurately Always Fairly Often Sometimes Infrequently Never
Difficulty with hand tools (scissors, screwdriver, calculator) Always Fairly Often Sometimes Infrequently Never
Experience car- or motion- sickness Always Fairly Often Sometimes Infrequently Never

OCULAR
One or both eyes turn in/out Always Fairly Often Sometimes Infrequently Never
Squints/covers/closes one eye during reading or close work Always Fairly Often Sometimes Infrequently Never
"Pulling" feeling around the eyes during reading or close work Always Fairly Often Sometimes Infrequently Never
Rubs eyes or blinks excessively Always Fairly Often Sometimes Infrequently Never
Eyes are overly sensitive to light Always Fairly Often Sometimes Infrequently Never
Eyes burn/water/sting during reading or computer work Always Fairly Often Sometimes Infrequently Never
Eyes feel tired/uncomfortable/sore when reading or doing near work Always Fairly Often Sometimes Infrequently Never
Must read text more than once to understand what was read Always Fairly Often Sometimes Infrequently Never
Vision is worse at the end of the day Always Fairly Often Sometimes Infrequently Never
Experienced doube vision, especially when reading or doing near workAlways Fairly Often Sometimes Infrequently Never
Words blur/lose focus/run together/come apart when reading Always Fairly Often Sometimes Infrequently Never
Vision is blurry when looking up from reading or close work Always Fairly Often Sometimes Infrequently Never
Dizziness or nausea when reading or doing near work Always Fairly Often Sometimes Infrequently Never
Feel sleepy/fall asleep during reading or near work Always Fairly Often Sometimes Infrequently Never
Difficulty changing focus between near and far targets Always Fairly Often Sometimes Infrequently Never

HEADACHES
If they complain of headaches, please complete the following:
Where are they located? Back Top Above ears Temples Behind eyes Forehead
More one side of the head than another? Equally both sides Left Right
How frequently? Rarely Once a month Every other week Once a week 2-4 times a week Daily
How long do they last? All day 4-10 hours 1-3 hours Less than 30 minutes
How severe are they on a scale of 1 to 10 (10=severe)?
Do you take anything or do anything to relieve the headaches?
Do your relief strategies work? Never Sometimes Yes-resolves headaches

REFLEXES
Please mark EACH BOX Yes or No for the following. If Yes, please describe in the space provided:
YES NO   Auditory or sensory processing concerns?
YES NO   Bedwetting after 5 years of age?
YES NO   Right/left confusion?
YES NO   Low muscle tone?
YES NO   Poor physical stamina?
YES NO   Physically timid / shy?
YES NO   "W" sitting instead of crossed legs?
YES NO   Difficulty with speech/articulation?
YES NO   Oversensitive to sound/loud noise?
YES NO   Emotionally sensitive?
YES NO   Difficulty maintaining eye contact?
YES NO   Sleep difficulty / disburbance?
YES NO   Difficulty following directional instruction?
YES NO   Poor posture?
YES NO   Difficulty cross patterning (skipping, marching, pedaling)?


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