Patient Forms

Patient Info
VSE
TBI
Progress Check
Follow up

What Concerns Brought You Here?(Please Include Dates if Relevant)?

Are you currently experiencing any of the following?(Please rate severity 0-4, 0=none, 4=severe)

Headaches:		Eyes tired:
Light Sensitivity		Neck Pain / Whiplash
Problems focusing:		Words move on page:
Nausea:		Disorientation:
Double Vision:		Motion / car sickness:
Clumsiness		Dizziness
Eye Pain:		Movement sensitivity:
Attention:		Memory problems:

How long have these Problems/Difficulty been observed?

How frequently do they occur? Always Daily Weekly Monthly

Other timeframe

Is there anything that makes these problems better?

Is there anything that makes these problems worse?

Are they getting better, staying the same, or worsening?

Developmental History

Full term pregnancy? Yes No

If no, explain

Was a Cesarean performed? Yes No

Were forceps/vacuum section used? Yes No

Explain any problems prior to / during / immediately after your/your child's birth:

At what age did you/your child do the following?

"Tummy time"

Creep (stomach off floor)

Crawl (stomach on floor)

Walk (without support)

Explain any concerns regarding you or your child's growth or development

Visual History

Eye Doctor's Name

Date of Last Evaluation

Reason for Last Visit Results and Recommendations

Medical History

Pediatrician / Primary Care Physician's Name

Date of Last Evaluation

Reason for Last Visit Results and Recommendations

Is there any history of the following?(Please check all that apply)

Symptom	Patient	Family	Who
High Blood Pressure
Diabetes
Glaucoma
Multiple Sclerosis
Epilepsy / Seizures
Amblyopia (Lazy Eye)
Strabismus (Eye Turn)
Learning Disability
ADD / ADHD
Autism

Please list any major injuries or illnesses (Ear infections, asthma, high fevers, allergies, car accidents, falls, etc)

What treatments were given for the above injuries or illnesses

Medications currently using, including vitamins and supplements

Have you or anyone else ever noticed the following symptoms with you/your child?(Check all that apply)

School

Is school enjoyable? Yes No

Specifically describe any school difficulties

List any special tutoring, therapy, and/or remedial assistance:

Overall schoolwork is Above Average Average Below Average

Subjects above average?

Subjects below average?

How much time on average is spent each day on homework assignments?

Family and Home

Please list the names and birth dates of any siblings

Sibling Name

DOB

Sibling Name

DOB

Sibling Name

DOB

Sibling Name

DOB

Sibling Name

DOB

Please indicate which adult you/your child lives with

Both Mother Father Self

List any traumatic family situations(Such as divorce, parental loss, separation, severe parental illness)

Is family life stable at this time? Yes No (If no please explain)

Lifestyle

Explain how your/your child's vision interferes with daily living(i.e. home, work, hobbies, etc)

What do you hope the Vision Therapy Program can do for you/your child?

List any other information you feel would be important in the patient's treatment

What concerns brought you here(Please Include Dates if Relevant)

Did you lose consciousness?

If yes, for how long?

Were you in a coma?

If yes, for how long?

Are you currently experiencing any of the following?(Please rate severity 0-4, 0=none, 4=severe)

Headaches		Eyes Tired
Light Sensitivity		Neck Pain / Whiplash
Problems Focusing		Words Move on Page
Nausea		Disorientation
Double Vision		Motion / Car Sickness
Clumsiness		Dizziness
Eye Pain		Movement Sensitivity
Attention		Memory Problems

How long have these problems been observed?

How frequently do they occur? Always Daily Weekly Monthly

Other time frame

Is there anything that makes these problems better?

Is there anything that makes these problems worse?

Are they getting better, staying the same, or worsening?

Developmental and Medical History

NOTE: The following section is anything prior to your current brain injury.

Explain any problems prior to / during / immediately after you/your child's birth

Please list any concerns with your development as a baby/child (to include coordination, speech, reading, etc)?

Visual History

Eye Doctor's Name

Date of Last Evaluation

Reason for Last Visit Results and Recommendations

Is there any history of the following?( Please check all that apply)

Symptom	Patient	Family	Who
High Blood Pressure
Diabetes
Glaucoma
Multiple Sclerosis
Brain Tumor
Stroke
Cataracts
Blindness
Amblyopia(Lazy Eye)
Strambiumus (Eye Turn)
Traumatic Brain Injury
Other

Please list any major injuries or illnesses (ear infection, asthma, high fevers, allergies, car accidents, falls)

What treatments were given for the above injuries or illnesses?

Medications currently using, including vitamins and supplements

Have you experienced any of the following(before or after the incident)

Lifestyle

How do you feel that your vision interferes with activities of daily living?

What activities comprise the majority of your daily life since your accident / injury?

What changes / limitations in your daily life do you attribute to your accident / injury?

What do you hope a Visual Rehabilitation Program can do for you?

Chief Concern

What Concerns Brought You Here (Please Include Dates if Relevant)?

Are you currently experiencing any of the following? (Please rate severity 0-4, 0=none, 4=severe)

Headaches		Eyes Tired
Light Sensitivity		Neck Pain / Whiplash
Problems Focusing		Words Move on Page
Nausea		Disorientation
Double Vision		Motion / Car Sickness
Clumsiness		Dizziness
Eye Pain		Movement Sensitivity
Attention		Memory Problems
Unusual visual demands

Medical History

Check any problems with the following in yourself:

Please list any major injuries or illnesses (Ear infections, asthma, high fevers, allergies, car accidents, falls, etc)

What treatments were given for the above injuries or illnesses

Medications currently using, including vitamins and supplements

Ocular History

Check all that apply to you or family members

Cataracts	Glaucoma
Macular Degeneration	Amblyopia (Lazy eye) Or Strabismus (Eye turn)
Other

Dilation

I would like to have dilation as part of my routine eye examination and realize that is not covered by my insurance plan. The fee is $25.

I decline dilation today

Contact Lens Fitting

There will be a $60 fee for all contact lens fittings. Please be advised that a contact lens examination may require additional appointments (At no charge up to 60 days from original appointment) before a contact lens prescription is released.

There will be a $75 fee for all other follow-up appointments.

Signature

The information above is true to the best of my knowledge.

Electronic signature

Date

Current Symptoms

Are you currently experiencing any of the following? (Please rate severity 0-4, 0=none, 4=severe)

Headaches		Eyes Tired
Light Sensitivity		Neck Pain / Whiplash
Problems Focusing		Words Move on Page
Nausea		Disorientation
Double Vision		Motion / Car Sickness
Clumsiness		Dizziness
Eye Pain		Movement Sensitivity
Attention		Memory Problems

How long have you been able to wear the therapeutic lenses/perform the therapy since you last saw the doctor? Example: 4 weeks

Were you able to wear the lenses full time? If not, please explain times worn. Example: Not able to wear while swimming (about 3 hours/day)

Is there anything else you feel the doctor should know?

Example: Vision started to feel "off" about 1 week ago

Frequent blinking	Frequent eye rubbing
Frowning with near work	Closing or covering one eye
Squints when reading	Eye turns in, out, up, or down
Bothered by light	Tilts head when reading and / or writing
Head close to paper	Moves head when reading
Uses finger when reading	Avoids reading
Fatigues with near tasks	Poor reading comprehension
Comprehension lessons with time	Reads slowly
Loses place easily when reading	Skips, rereads, or omits words
Re-reads entire lines of print	Confuses words with same beginning and end
Problem recognizing same words on different page	Words move on page
Reports confusion of what is seen	Reverses letters or words
Confuses right and left	Difficulty with memory
Poor recall of visual tasks	Better recall for hearing than seeing
Responds better orally than writing	Knows answers but tests poorly
Short attention span / loses interest	Vocalizes when reading silently
School performance below potential	Difficulty copying from chalkboard/smart board
Writes or prints poorly	Writes neatly but slowly
Awkward or immature pencil grip	Poor large motor coordination
Poor fine motor coordination	Dislikes / avoids sports
Difficulty catching / hitting a ball

One eye turns in, out, up, or down	Before	After	None
Movement of objects in the environment is bothersome	Before	After	None
Fluorescent light is bothersome	Before	After	None
Patterned wallpaper or carpets are bothersome	Before	After	None
Lose place often when reading	Before	After	None
Words jump or move around when reading	Before	After	None
Discomfort when reading	Before	After	None
Loss of interest / Concentration when doing close work	Before	After	None
Orient writing / Drawing poorly on page	Before	After	None
Squinting, covering or closing one eye	Before	After	None
Avoid reading or writing	Before	After	None
Objects jump in and out of field of view	Before	After	None
Reduced depth preception	Before	After	None
Tunnel vision / Loss of visual field	Before	After	None
Flashes of light	Before	After	None
Difficulty following a series of directions	Before	After	None
Dislikes heights	Before	After	None
Awkward, poor balance	Before	After	None
Get lost often	Before	After	None

Ears, Hearing, Nose, Sinus, Throat	Heart (Blood pressure, cholesterol)
Lungs (Emphysema, difficulty breathing)	Gastrointestinal system (GERD, irritable bowel)
Kidney or urinary system (UTI, Stones)	Cancer
Pregnant	Endocrine system (Diabetes, thyroid, PMS, Anxiety)
Skin (Rash, Eczema, Psoriasis)	Blood (Anemia, Hypercoagulation)
Muscles / Joints (Arthritis)	Brain / Spinal Cord (Cyst, tumor, injury)
Other

Patient Information

Billing information

Parent/Guardian Information

Emergency Contact

Permission to Post Photography/Video/Testimonial of Patient

Payment Information

Are you a Medicare B Beneficiary?(Check Yes or No and read agreement below)

Acknowledgement of Receipt of Notice of Privacy for Arizon Vision Therapy Center

Developmental History

Visual History

Medical History

Is there any history of the following?(Please check all that apply)

Have you or anyone else ever noticed the following symptoms with you/your child?(Check all that apply)

School

Family and Home

Lifestyle

Developmental and Medical History

NOTE: The following section is anything prior to your current brain injury.

Visual History

Have you experienced any of the following(before or after the incident)

Lifestyle

Chief Concern

Medical History

Ocular History

Dilation

Contact Lens Fitting

Signature

Current Symptoms