Patient Information
Billing information
Parent/Guardian Information
If patient is a minor, please fill out Guardian information; otherwise, please skip to
the Emergency Contact section:
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)
The information above is true to the best of my knowledge.
Are you currently experiencing any of the following?(Please rate severity
0-4,
0=none, 4=severe)
Headaches: |
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Eyes tired: |
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Light Sensitivity |
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Neck Pain / Whiplash |
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Problems focusing: |
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Words move on page: |
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Nausea: |
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Disorientation: |
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Double Vision: |
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Motion / car sickness: |
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Clumsiness |
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Dizziness |
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Eye Pain: |
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Movement sensitivity: |
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Attention: |
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Memory problems: |
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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
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 |
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Dizziness |
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Eye Pain |
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Movement Sensitivity |
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Attention |
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Memory Problems |
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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
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 |
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Medical History
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Ocular History
Dilation
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.
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 |
|