Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Miss Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

Title	First	Last	MI	Suffix
Mr. Miss Mrs. Ms. Dr. Rev.

Copy Address From Above
Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Adult History

ADULT HISTORY

Only complete this Tab if the patient is 18 years of age or older.

Referral Information

How did you hear about our office? Referred by friend/family Referred by professional Self-referred If you were referred, by whom?

Address: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City: Zip:

If you were referred, would you like a report sent to this office? Yes No Fax: Phone:

VISUAL HISTORY

Date of last evaluation:

If yes, Doctor's Name:

Has there been a previous eye/vision exam? Yes No

Reason for last exam:

Results and recommendations:

If glasses or contact lenses were prescribed and worn, how often?


If glasses or contact lenses were prescribed, but not used, why not?


PRESENT SITUATION

What is the main reason you need a vision evaluation?


Who first noted the visual difficulties? How long has this problem/difficulty been observed?

VISUAL SYMPTOMS

After you consider each question, assign a number that best applies to the patient. Never = 0, Seldom = 1, Occasionally = 2, Frequently = 3, Always = 4.

Double Vision	0 1 2 3 4 Other	Omits small words while reading	0 1 2 3 4 Other
Words run together while reading	0 1 2 3 4 Other	Skips / repeats lines while reading	0 1 2 3 4 Other
Falls asleep reading	0 1 2 3 4 Other	Poor eye - hand coordination (handwriting, hand tools)	0 1 2 3 4 Other
Car / motion sickness	0 1 2 3 4 Other	Misaligns digits / columns	0 1 2 3 4 Other
Dizzy / nauseated with near work	0 1 2 3 4 Other	Clumsy / Knocks over things	0 1 2 3 4 Other
Head tilt / Close one eye when reading	0 1 2 3 4 Other	Writes uphill or downhill	0 1 2 3 4 Other
Avoids near work / reading	0 1 2 3 4 Other	Avoids sports / games	0 1 2 3 4 Other
Does not judge distances accurately	0 1 2 3 4 Other	poor / inconsistent performance in sports	0 1 2 3 4 Other
Trouble keeping attention on reading	0 1 2 3 4 Other	Reading comprehension down / decrease over time	0 1 2 3 4 Other
Blur when looking at near	0 1 2 3 4 Other	Difficulty completing assignments on time	0 1 2 3 4 Other
Sees worse at end of the day	0 1 2 3 4 Other	Difficulty with money concepts, making change	0 1 2 3 4 Other
Headaches with near work (reading, writing)	0 1 2 3 4 Other	Does not manage time well	0 1 2 3 4 Other
Burning, itchy, watery eyes	0 1 2 3 4 Other	Loses belongings / things	0 1 2 3 4 Other
Difficulty copying from the board	0 1 2 3 4 Other	Forgetful / poor memory	0 1 2 3 4 Other
Holds reading material close	0 1 2 3 4 Other	Says "I'cant" before trying	0 1 2 3 4 Other

In addition, please indicate the following signs/symptoms:

Eye Teaming: Please select all that apply.	difficulty walking up or down steps dislikes 3-D movies letters, words, or lines "move" on the page one eye turns (in, out, up, or down) at any time Other
Eye Focusing: Please select all that apply:	blinks eyes excessively during near visual tasks difficulty changing focus between far and near difficulty focusing attention for required time discomfort during reading, computer use, or near work squints to see Other
Eye Tracking: please select all that apply.	loses place when reading moves head while reading uses finger or marker when reading Other
Orientation: Please select all that apply.	confuses right-left directions dislikes playing sports eye-body coordination is difficult writes neatly, but slowly writes or prints poorly or slowly Other
Visual Perception and Cognition: Please select all that apply.	confuses minor likenesses or differences fails to recognize the same word in the next sentence or page prefers audio books to reading poor ability to remember what is read poor word attack skills remembers better what is heard than seen reverses letters, numbers, and/or words vocalizes or moves lips while reading "silently" Other

List any other complaints / concerns you have regarding your vision:

MEDICAL HISTORY

Primary Care Provider's Name:

Address: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City: Zip:

Fax: Phone:

Are you generally healthy? Yes No If no, please explain:

Have you had or currently have any problems in the following areas:

Learning disabilities:	Yes No Not sure Other
Cerebral Palsy:	Yes No Not sure Other
Autism:	Yes No Not sure Other
Developmental delay:	Yes No Not sure Other
Brain Injury:	Yes No Not sure Other (if yes, please fill out ABI History Tab)
Seizure disorders:	Yes No Not sure Other
ADD / ADHD	Yes No Not sure Other
Diabetes:	Yes No Not sure Other
High blood pressure:	Yes No Not sure Other
Heart disease:	Yes No Not sure Other
Kidney disease:	Yes No Not sure Other
Thyroid disease:	Yes No Not sure Other
Cancer:	Yes No Not sure Other
Blindness:	Yes No Not sure Other
Macular Degeneration:	Yes No Not sure Other
Amblyopia (lazy eye):	Yes No Not sure Other if yes, please fill out AMB History Tab
Strabismus (eye turn):	Yes No Not sure Other If yes, fill out STRAB History TAB
Glaucoma:	Yes No Not sure Other

Other (please explain):

Have your immediate family members had or currently have any problems in the following areas:

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

Please list all medications that you/your child currently uses - including over the counter medications, eye drops, vitamins/supplements - with the name and condition treated e.g. Atenolol (high blood pressure):

List any MEDICATION ALLERGIES

List any serious illnesses, bad falls, surgeries, immunization reactions, etc. with age and complications/outcomes:

VISUAL ACTIVITIES

How many hours per day are spent on screen time for work/school and play (i.e. TV, tablet, computer, smart phone, e-reader)?

Which sports do you play? Describe performance and any skill you wish to improve.

What other activities/hobbies do you enjoy?

Are there any activities you would like to participate in, but don't?

EMPLOYMENT OR SCHOOL

Current position:

Major course of study:

Describe briefly your daily activities at work or school?

Do you feel achievement is up to potential in work or school?

Yes No Not sure Other

Do you feel you are getting adequate return for the amount of effort you put into a task?

Yes No Not sure Other

How many hours per day are spent working at near distances (e.g. reading, writing)?

Does your work or course of study demand comprehension from the written word?

Yes No Not sure Other

Child History

REFERRAL INFORMATION

Only complete this Tab if the patient is under 18 years of age.

How did you hear about our office? Referred by friend/family Referred by professional Self-referred If you were referred, by whom?

Address: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City: Zip:

If you were referred, would you like a report sent to this office? Yes No Fax: Phone:

VISUAL HISTORY

Date of last evaluation: Has there been a previous eye/vision exam? Yes No If yes, Doctor's Name:
Reason for last exam:
Results and recommendations:

If glasses or contact lenses were prescribed and worn, how often?

If glasses or contact lenses were prescribed, but not used, why not?


PRESENT SITUATION

What is the main reason your child needs a vision evaluation?


How long has this problem/difficulty been observed? Who first noted the visual difficulties?
List any other complaints/concerns you or your child makes regarding his/her vision:


VISUAL SYMPTOMS

After you consider each question, assign a number that best applies to the patient. Never = 0, Seldom = 1, Occasionally = 2, Frequently = 3, Always = 4.

Double Vision	0 1 2 3 4 Other	Omits small words while reading	0 1 2 3 4 Other
Words run together while reading	0 1 2 3 4 Other	Skips / repeats lines while reading	0 1 2 3 4 Other
Falls asleep reading	0 1 2 3 4 Other	Poor eye - hand coordination (handwriting, hand tools)	0 1 2 3 4 Other
Car / motion sickness	0 1 2 3 4 Other	Misaligns digits / columns	0 1 2 3 4 Other
Dizzy / nauseated with near work	0 1 2 3 4 Other	Clumsy / Knocks over things	0 1 2 3 4 Other
Head tilt / Close one eye when reading	0 1 2 3 4 Other	Writes uphill or downhill	0 1 2 3 4 Other
Avoids near work / reading	0 1 2 3 4 Other	Avoids sports / games	0 1 2 3 4 Other
Does not judge distances accurately	0 1 2 3 4 Other	poor / inconsistent performance in sports	0 1 2 3 4 Other
Trouble keeping attention on reading	0 1 2 3 4 Other	Reading comprehension down / decrease over time	0 1 2 3 4 Other
Blur when looking at near	0 1 2 3 4 Other	Difficulty completing assignments on time	0 1 2 3 4 Other
Sees worse at end of the day	0 1 2 3 4 Other	Difficulty with money concepts, making change	0 1 2 3 4 Other
Headaches with near work (reading, writing)	0 1 2 3 4 Other	Does not manage time well	0 1 2 3 4 Other
Burning, itchy, watery eyes	0 1 2 3 4 Other	Loses belongings / things	0 1 2 3 4 Other
Difficulty copying from the board	0 1 2 3 4 Other	Forgetful / poor memory	0 1 2 3 4 Other
Holds reading material close	0 1 2 3 4 Other	Says "I'cant" before trying	0 1 2 3 4 Other

In addition, please indicate the following signs/symptoms:
Please note that near visual tasks for preschoolers include coloring, looking at books, and playing with toys. For children grades K-12, near visual tasks include reading, writing, and computer use.

Eye Teaming: Please select all that apply.	difficulty walking up or down steps dislikes 3-D movies letters, words, or lines "move" on the page one eye turns (in, out, up, or down) at any time Other
Eye Focusing: Please select all that apply:	blinks eyes excessively during near visual tasks difficulty changing focus between far and near difficulty focusing attention for required time discomfort during reading, computer use, or near work squints to see Other
Eye Tracking: please select all that apply.	loses place when reading moves head while reading uses finger or marker when reading Other
Orientation: Please select all that apply.	confuses right-left directions dislikes playing sports eye-body coordination is difficult writes neatly, but slowly writes or prints poorly or slowly Other
Visual Perception and Cognition: Please select all that apply.	confuses minor likenesses or differences fails to recognize the same word in the next sentence or page prefers audio books to reading poor ability to remember what is read poor word attack skills remembers better what is heard than seen reverses letters, numbers, and/or words vocalizes or moves lips while reading "silently" Other

List any other complaints / concerns you have regarding your child's vision:

MEDICAL HISTORY

Primary Care Provider's Name:

Address: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City: Zip:

Fax: Phone:

is your child generally healthy? Yes No If no, please explain:

Has your CHILD had or currently have any problems in the following areas:

Learning disabilities:	Yes No Not sure Other
Cerebral Palsy:	Yes No Not sure Other
Autism:	Yes No Not sure Other
Developmental delay:	Yes No Not sure Other
Brain Injury:	Yes No Not sure Other (if yes, fill out ABI History Tab)
Seizure disorders:	Yes No Not sure Other
ADD / ADHD	Yes No Not sure Other
Diabetes:	Yes No Not sure Other
High blood pressure:	Yes No Not sure Other
Heart disease:	Yes No Not sure Other
Kidney disease:	Yes No Not sure Other
Thyroid disease:	Yes No Not sure Other
Cancer:	Yes No Not sure Other
Blindness:	Yes No Not sure Other
Macular Degeneration:	Yes No Not sure Other
Amblyopia (lazy eye):	Yes No Not sure Other If yes, fill out AMB History TAB
Strabismus (eye turn):	Yes No Not sure Other If yes, fill out STRAB History TAB
Glaucoma:	Yes No Not sure Other

Other (please explain):

Have your child's immediate family members had or currently have any problems in the following areas:

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

No Parent(s) Sibling(s) Grandparent(s) Other

Please list all medications that you/your child currently uses - including over the counter medications, eye drops, vitamins/supplements - with the name and condition treated e.g. Atenolol (high blood pressure):

List any MEDICATION ALLERGIES

List any serious illnesses, bad falls, surgeries, immunization reactions, etc. with age and complications/outcomes:

SPECIAL TESTING

Has an educational evaluation been performed? Yes No Not sure
Results: Date/By whom?

Has a neurological evaluation been performed? Yes No Not sure
Results: Date/By whom?

Has a psychological evaluation been performed? Yes No Not sure
Results: Date/By whom?

Has an occupational therapy evaluation been performed? Yes No Not sure
Results/Dates of Therapy: Date/By whom?

Has a physical therapy evaluation been performed? Yes No Not sure
Results/Dates of Therapy: Date/By whom?

Yes No Not sure Has a speech/hearing evaluation been performed?
Results/Dates of Therapy: Date/By whom?

DEVELOPMENTAL HISTORY

Delivery type? Natural Cesarean Pregnancy length? My child is: adopted biological foster other
Birth weight:

Describe any health problems the mother experiences during the pregnancy:

Describe any complications before, during, or immediately following delivery (vacuum, forceps, pitocin, oxygen deprivation, use of oxygen, etc.)?

Describe any concerns related to your child's growth or development?

At what age did your child crawl? Did your child crawl (stomach on the floor)? Yes No Not sure

At what age did your child creep? Did your child creep (on all fours)? Yes No Not sure

Did your child frequently walk on his/her toes? Yes No Not sure At what age did your child walk?

At what age did your child say his/her first words?



Is your child generally well-coordinated or clumsy? Did your child have difficulty learning to tie shoes or button clothes?

Child's dominant hand? right left undetermined

EDUCATION HISTORY

Classroom setting: Mainstream Honors Special Education Current grade: School:

Address: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City: Zip:

Fax: Phone:

Would you like a report sent to the teacher? No Yes Teacher:
Would you like a report sent to the principal? No Yes Principal:

Would you like a report sent to the school specialist? School Specialist:

At what age did your child start kindergarten?

Has a grade been repeated? No Yes
If yes, which grade and why?

Least favorite subject(s): Favorite subject(s): Does your child like school?

What grade level does your child read at? Does your child read voluntarily or for pleasure? Yes No Not sure Does your child like reading? Yes No Not sure
Which school subjects are:

Above average:
Average:
Below average:

Has your child had special tutoring, therapy, and/or remedial assistance (e.g. IEP or 504)? Yes No Not sure
If yes, describe the type of assistance, how often it occurs, and for how long it has been going on.

To what extent is assistance needed with homework?
Does your child appear frustrated when doing school/homework? Yes No Not sure
Is a great deal of effort/time needed to maintain this level of performance? Average Above average Below average Not sure Overall academic performance is:

Does/Do the teacher(s) feel achievement is up to potential? Yes No Not sure Do you feel achievement is up to potential? Yes No Not sure

GENERAL BEHAVIOR

Are there any behavior problems at school or home? Yes No not sure
If yes, please describe:

NUTRITIONAL INFORMATION

Is a special diet in place? Yes No Not sure Currently investigating
If yes, please describe: Are there any food allergies/sensitivities? Yes No Currently investigating Not sure
What is your child's attitude towards sweets? Indifferent to sweets Likes sweets Craves sweets

LEISURE TIME ACTIVITIES

How many hours per day does your child play computer/video games?

Which sports does your child play? Describe performance and any skill the child wishes to improve.


What other activities/hobbies does your child enjoy?

Are there any activities your child would like to participate in, but doesn't?

FAMILY AND HOME

Please indicate which adult(s) your child lives with: mother father stepmother stepfather grandmother grandfather aunt uncle adoptive parents foster parents

If yes, at what age(s): Has your child ever been through a traumatic family situation (e.g. parental loss or severe illness, divorce, separation)? Yes No Not sure

What situation?

Is family life stable at this time? If no, please explain: Does your child seem to have adjusted? Yes No Not sure

GIVE A BRIEF DESCRIPTION OF YOUR CHILD AS A PERSON:

ABI History

AMB History

Only complete this Tab if the patient has a history of an acquired brain injury

Type of injury: open-head (bleeding) closed-head (non-bleeding) Cause of injury: motor vehicle collision fall blow to the head stroke aneurysm hemorrhage umbilical cord around neck industrial accident medication-related drug abuse poison/toxic substance exposure carbon monoxide exposure State where injury occurred: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Date of injury:

What part of the head was affected? face forehead back of head top of head right side left side
Were you in a coma? Yes No Was there a loss of consciousness? No Not sure Yes, 30 minutes or less Yes, 31 minutes to 59 minutes Yes, 1 hour to 5 hours 59 minutes Yes, 6 hours to 24 hours Yes, greater than 24 hours
Symptoms immediately following the injury: blurred vision disorientation dizziness double vision flashes of light headache loss of balance loss of memory neck pain/whiplash pain in/around eyes restricted field of view restricted motion vomiting
If yes, date range you were out of work: Did the injury occur at work? Yes No

INITIAL TREATMENT


When was the first doctor seen regarding your injury? Specialty:
Doctor's Name:
What were you and your family told? Was hospitalization required? Yes No If yes, for how long?
What did the initial treatments consist of?

What prognosis/recommendations were given?

SUBSEQUENT/OTHER PROFESSIONAL CARE

Has a neurological evaluation been performed? Yes No Not sure
Results: Date/By whom?

Has a psychological evaluation been performed? Yes No Not sure
Results: Date/By whom?

Has an occupational therapy evaluation been performed? Yes No Not sure
Results/Dates of Therapy: Date/By whom?

Has a physical therapy evaluation been performed? Yes No Not sure
Results/Dates of Therapy: Date/By whom?

Has a speech/hearing evaluation been performed? Yes No Not sure
Results/Dates of Therapy: Date/By whom?

LIFESTYLE

Do you feel your vision interferes with activities of daily living? Yes No Not sure

Is this new since the injury? Yes No

If yes, please explain (Please include effects involving home, work, hobbies, social, and personal relationships.):

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

What activities can you no longer engage in due to your visual or other difficulties?

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

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

What goals have you set up that you would like us to help you meet? What are your short term and long term goals?

AMB History

AMB History

Only complete this Tab if the patient has been diagnosed with amblyopia (lazy eye).

Is there family history of a decreased vision from a disease or other condition? Yes No Not sure
If yes, please explain:
Was there any related trauma, disease, or condition that preceded or accompanied the onset of the decreased vision? Yes No Not sure
If yes, please explain:
Is vision decreased despite an updated spectacle or contact lens prescription? Yes No
Was vision loss gradual or sudden? Gradual Sudden At what age was amblyopia diagnosed?

Is there an eye turn associated with the amblyopia? Yes No Not sure In which eye is the amblyopia? Right eye Left eye Both eyes
Has treatment in the form of patching or eye drops ever been administered? Yes No Not sure
If yes, please explain, including the doctor's name, eye that was being patched and numbers of hours/day (or eye that was given drops and how often drops were administered), age at which treatment was started and stopped (if applicable).


Were any improvements noted? Yes No Not sure
Were you or your child resistant to patching? Yes No Not sure Not applicable Were you satisfied with the results of this treatment? Yes No
Has there been any optometric vision therapy? Yes No Not sure
If yes, please explain, including the doctor's name, type of therapy, duration, age at which it started, age at which treatment was stopped, and estimation of results.

What are your vision goals? Please explain:

STRAB History

STRAB History

Only complete this Tab if the patient has been diagnosed with or you have observed the patient have a crossed or wandering eye.

What is your biggest concern about the eye turn?
If yes, please explain: Is there family history of an eye turn from a disease or other condition? Yes No Not sure
If yes, please explain: Are there any other health problems? Yes No
Was there any related trauma, disease, or condition that preceded or accompanied the onset of the eye turn? Yes No Not sure
If yes, please explain:
At what age was the eye turn first noticed/suspected?
Who first noticed/suspected the eye turn?

Did you ever notice one or both eyes shaking rapidly (nystagmus)? Yes No Not sure Did one pupil ever appear to be larger than the other? Yes No Not sure
Do you/ Does your child ever report seeing double? Yes No Not sure
If yes, the double vision is noticed when looking: at near in the distance to the right to the left up down
Is it always the same eye that turns? Yes No Which eye is turning? Right eye Left eye Both eyes
If no, please explain under which conditions the turn is present (e.g. when tired, ill). Is the eye turn constant? Yes No Not sure
The eye turns more when looking: at near in the distance to the right to the left up down In which direction does the eye turn? In Out Up Down Rotates
Does the eye turn less with glasses on? Yes No Not sure The eye turn is... improving worsening stable
Has there been any surgical treatment? Yes No Not sure
If yes, please describe the surgery, including the doctor's name, age surgery was performed, the number of operations, the eye operated on, and the results.

If not, please explain: Were you satisfied with the results of surgery? Yes No Not sure
If not, please explain: Was the surgeon satisfied with the results of surgery? Yes No Not sure
Has there been any vision therapy?
Yes No Not sure
If yes, please describe the type of therapy, including the doctor's name, duration, age which it was started, and estimation of results:

Are you here for a second opinion regarding surgery or further treatment? Yes No
What are your vision goals?

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