Online Patient Form

After completing all the forms, please submit your data using the button on the final page. Thank you!

Demographics

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Title

First

Last

Address:

Suite/Apt #:

City:

State

ZipCode:

Home Phone:	Preferred Contact:
Cell Phone:
Email
Birthday
Sex Male Female F

Please click the buttons below to submit additional information.

Medical

Insurance Name:

Insurance ID:

Not Primary on Account: Not Primary

Primary on Account

	Last	First	MI
Name:

Relationship to Insured: Spouse Child Other

Sex: Male Female

Address:

City:

State:

Zip:

Phone Number:

Birthday:

Employer/School:

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?: Yes No
Last Visit Date: For What Reason? Is your child generally healthy?
Medications:
Allergies to Medications:
___________________________________

List major illnesses, injuries, or high fevers:

Event/Condition/Age/Severity/Complications: Event/Condition/Age/Severity/Complications:
___________________________________

Neuro/psych eval: Yes No By Whom?
Occupational Therapy eval? Yes No 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: ___________________________________

System Review

NOTICE OR COMPLAINS OF:

Eye turns in / out: Yes No*** Squints / Blinks a lot: Yes No Covers / Closes one eye: Yes No Lacks interest in looking at objects: Yes No*** Rubs eyes excessively: Yes No Reddened or encrusted eyelids: Yes No Eyelid Droops: Yes No Poor tracking / eye movements: Yes No Head tilt / Face turn: Yes No Stumbles over objects / clumsy: Yes No Poor motor control: Yes No Head injury / trauma: Yes No

DOES CHILD HAVE OR HAD:

Eye injury or surgery: Yes No*** Lazy eye / Amblyopia: Yes No*** Patching: Yes No*** Vision Therapy / Orthoptics: Yes No*** Surgery / Hospitalizations: Yes No Breathing problems: Yes No Gastrointestinal problems: Yes No Musculoskeletal problems: Yes No Neurological problems: Yes No Development delayed: Yes No Ear / Nose / Throat problems: Yes No

*** If yes, please complete Strabismus / Amblyopia section.

___________________________________
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 birthweight:
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: 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:
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?

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

Adult History

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 Strabismus / Wandering Eye ** if yes, complete Strabismus section. Retinal Detachment Implant Lens Left Eye Hypertensive Retinal Disease Amblyopia / Lazy Eye ** if yes, complete Amblyopia section. Dry Eye Syndrome Diabetic Retinal Disease Glaucoma
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 section under Additional Info.
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:

___________________________________

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?

Additional Info

Strabismus/Ambylopia 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:

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?

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 to drive 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.

Dizziness or motion sickness: Before After
Dislike heights: Before After
Difficulty understanding what is seen: Before After
Difficulty using both sides of the body together: Before After
Difficulty recognizing words: Before After
Memory problems: Before After
Difficulty recognizing faces: Before After
Difficulty focusing one or both eyes: Before After
Difficulty remembering names of objects: Before After
Frequent squinting or blinking: Before After
Difficulty remembering people's names: Before After
Vision appears unstable or shifts from eye to eye: Before After
Unusual head tilt or turn: Before After
Difficulty with time management: Before After
Portions of a page or objects appear to be missing: Before After
Difficulty finding objects when grouped together: Before After
People/things suddenly appear unexpectedly from one side: Before After
Patterned wallpaper or carpets are bothersome: Before After
Awkward or poor balance: Before After
Looking to the side of objects to see them better: Before After
Ears ringing/Tinnitus: Before After
Tunnel vision: Before After
Confusion/Disorientation: Before After
Difficulty concentrating on visual tasks: Before After
Gets lost often: Before After
Difficulty maintaining eye contact: Before After
Bothered by noises: Before After
One eye turns in, out, up or down: Before After
Bothered by touch: Before After
Flashes of light: Before After

What activities can you no longer engage in due to your accident / injury?

Dry Eye History

Over the past week, which of the following eye symptoms have you experienced?
Glare Eye ache Night Driving Problems Redness Burning Eye lids swollen or red along the lash margin Tearing / Watery eyes Stinging Artificial Tear drops help but do not last long enough Dryness Dry Mouth Mattering on your eyelids when you wake up in the morning Light Sensitivity Itching Decreased contact lens wearing time Burning in the morning Grittiness Vision fluctuates from clear to blurry especially in the morning, after reading, watching TV, computer use or driving.
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?

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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