Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

Birthday

*This field is required

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Neuro-Optometry Health History

Background

Who referred you to our clinic? Family, Friend, Medical Professional, etc. Please List

I watched the introduction video on Thrive With Vision's website?

Yes

Date of Injury / Incident

Type of Injury / Incident

Motor Vehicle

Medication-Related

Cord Around Neck

Stroke

Aneurysm

Poison or Toxic Substance

Blow To Head

Drug Abuse

Carbon Monoxide Poisoning

Fall

Hemorrhage

Other:

Industrial Accident

Drowning

What part of your head was affected?: (Check All That Apply)

Forehead

Right Side

Back of Head

Face

Left Side

Top of Head

Was the Injury/Incident OPEN HEAD (bleeding) or CLOSED HEAD (non-bleeding)?

OPEN HEAD (bleeding)

CLOSED HEAD (non-bleeding

Did you lose conciousness?

Yes

If Yes, for How long

Were you in a coma?

Yes

If Yes, for How long

SYMPTOMS IMMEDIATELY FOLLOWING INJURY / INCIDENT: (check all that apply)

Double Vision

Vomiting

Loss of Memory

Pain In or Around Eyes

Flashes of Light

Restricted Vision (partial vision loss)

Headache

Disorientation

Restricted Motion

Blurred Vision

Neck Pain / Whiplash

Other:

Dizziness

Loss of Balance

Initial Treatment

When did you first see a doctor regarding your injury / incident?

Name of Doctor / Speciality

Where were you seen?

Were you hospitalized?

Yes

If Yes, for How long

What were you and your family told?

What did the initial treatments consist of?

What prognosis / recommendations were you given?

Why do you feel the need for a vision evaluation?

Current Providers

Physicians Names / Locations: (list all)

Date(s) of last evaluation/treatment

Scheduled Follow up?

Yes

If yes, then, when scheduled?

Occupational Therapists:

Name / Locations:

Currently being treated?

Yes

If yes, Date started?

Treatment with binasal occlusion (tape in center of glasses)?

Yes

If yes, outcome?

Treatment with light therapy (Syntonics) recommended?

Yes

Currently being treated with light therapy (Syntonics)?

Yes

If yes, Date started?

What activity are you working on with them? (ie: dressing yourself, vision activities)

Cranial-Sacral Therapy or Myofacial Release initiated?

Name / Locations:

Currently being treated?

Yes

If yes, Date started?

Other Providers / Practitioners (ie: nutritionist, functional neurology, acupuncture):

Name / Locations:

Currently being treated?

Yes

If yes, Date started?

What Treatments were recommended?

Neuropsychologist Name:

Date started?

Results and Recommendations:

Last Eye Exam Information

Date / Where?

Treatment / Recommendations:

Outcome of Treatment:

Were any additional tests, treatments, or therapies recommended concerning your vision?

Yes

If yes, explain:

Results and Recommendations:

Physical Therapists:

Name / Locations:

Currently being treated?

Yes

If yes, Date started?

Mention Vestibular status / percentage?

What condition are they treating? (ie: balance, muscle pain, strengthening)

Speech / Language Therapists:

Name / Locations:

Currently being treated?

Yes

If yes, Date started?

Chiropractic:

Name / Locations:

Currently being treated?

Yes

If yes, Date started?

Manual Therapist:

Name / Locations:

Currently being treated?

Yes

If yes, Date started?

Neurologist Name:

Currently being treated?

Yes

If yes, Date started?

Results and Recommendations:

CT / MRI Performed?

Date Performed?

Results:

Have You Ever Had:

Eye Injuries?

Yes

If yes, explain:

Eye Surgeries?

Yes

If yes, explain:

Eye Disease / Eye Conditions?

Yes

If yes, explain:

SYMPTOMS

DO YOU CURRENTLY EXPERIENCE ANY OF THE FOLLOWING? (Check ALL That Apply!)
Symptoms:	PRESENT BEFORE INJURY?	ARE YOU CURRENTLY BEING TREATED?
Blurred Vision At Distance	Yes No	Yes No
Blurred Vision At Near	Yes No	Yes No
Difficulty changing focus near to far (takes some time)	Yes No	Yes No
Double Vision	Yes No	Yes No
Words jump or move around when reading	Yes No	Yes No
Pain with movement of eyes	Yes No	Yes No
Eyes ache, pain in or around eyes	Yes No	Yes No
Dizziness	Yes No	Yes No
Vertigo (world spins)	Yes No	Yes No
Tunnel vision or partial vision loss	Yes No	Yes No
Flashes, floaters, other	Yes No	Yes No
Ringing in your ears	Yes No	Yes No
Eye redness, burning, watery, itchy	Yes No	Yes No
Headaches	Yes No	Yes No
Lose place often when reading	Yes No	Yes No
Short attention span for reading or writing	Yes No	Yes No
Skip words frequently when reading	Yes No	Yes No
Loss of interest / concentration when doing close work	Yes No	Yes No
Brightness / Fluorescent lights are bothersome	Yes No	Yes No
Bothered by noises	Yes No	Yes No
Bothered by touch	Yes No	Yes No
Motion sickness / car sickness	Yes No	Yes No
Movement of objects in the background is bothersome	Yes No	Yes No
Patterened wallpaper or carpets are bothersome	Yes No	Yes No
Awkward, poor balance	Yes No	Yes No
Confusion / disorientation	Yes No	Yes No
Difficulty with memory	Yes No	Yes No
Difficulty with sleep	Yes No	Yes No
Difficulty getting to sleep, staying asleep or both	Yes No	Yes No

If Yes, what is the reason you have difficulty with sleep? (anxiety, pain, frequent urination, etc.)

EMPLOYMENT / EDUCATION INFORMATION (if applicable)

What is your current employment position?

If a student, what is the major course of study?

How many hours daily are spent at a desk?

How many hours daily are spent working at near distance?

How many hours daily are spent reading / studying?

How many hours daily are spent with a computer?

Has 'Return to Work' been initiated?

If Yes, List provider responsible:

Has 'Return to Play' been initiated?

If Yes, List provider responsible:

Please choose from the menu options or select the option to type in your own text. Thank you!

Routine Eye Care Health History

Please choose from the menu options

Eye History

Do you experience, or have you experienced any of the following? (Check all that apply from the drop-down list)

Do you currently use any of these eyedrops?

Have you had any of the following? (check all that apply from the drop-down list)

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Age of this pair of contact lens?

Do you sleep in your contact lens?

Medical History:

Medications - Please list all prescription medications you are taking. No Medications

Over the Counter Medications - Please list any over the counter medication you are taking; for example - ibuprofen, acetaminophen, etc.

Vitamins - Please list any vitamins/minerals you are taking.

Drug allergies - Please list any medications that you are allergic to or have had an adverse reaction.

Please Describe any Injuries, Surgeries, or Hospitalizations:

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Diabetes

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

Do you experience, or have you experienced any of the following? (Check all that apply from the drop-down list)

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Patient information

Billing information

Neuro-Optometry Health History

Background

Initial Treatment

Current Providers

SYMPTOMS

EMPLOYMENT / EDUCATION INFORMATION (if applicable)

Please choose from the menu options or select the option to type in your own text. Thank you!

Routine Eye Care Health History

Please choose from the menu options

Eye History

Contact Lens Wearers only:

Medical History:

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Family Medical History

Has anyone in your family, living or deceased, ever been diagnosed with the following? If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Family Eye History

Has anyone in your family, living or deceased, ever been diagnosed with the following? If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Review Of Systems

Do you experience, or have you experienced any of the following? (Check all that apply from the drop-down list)

Social History

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)