Online Patient Form


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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Spouse/Guardian Do you have the following?:

Medical History



Reason for Visit:
Secondary Reasons:

Medications:
Please describe any injuries or surgeries you have had:

Over The Counter Medications:
Vitamins: Drug Allergies:

Primary Care Physician:
Pregnant Or Nursing:
Pharmacy:


Do you have any of these medical conditions? If yes, please describe:

    Yes   No
Blurry Vision       
Fluctuating Vision       
Vision Loss       
Distorted Vision       
Double Vision       
Squinting       
Light Sentistive       
Dry Eyes       
Itchy Eyes       
Burning Eye       
Gritty/Sandy Eyes       
    Yes   No
Flashing Lights       
Floaters       
Eye Pain       
Eye Redness       
Headaches       
Reading Difficulties       
Ocular Fatigue       
Balance Difficulty       
Frequent Falls       
Bumping into Objects       
 

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

    Parent   Sibling   Other   None
Glaucoma                          
Macular Degen                          
Retinal Detach                          
Poor Vision                          
Cross/Lazy Eye                          
Diabetes                          
Hypertension                          
Heart Disease                          
Stroke                          
Cancer                          
Other:

Review of Systems

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

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune: Eyes:
Developmental Other:

Social History

Hobbies: STD's:

Smoking Status:
Alcohol Use:
Illegal Drug Use:

Race: Ethnicity: Preferred Language:

Vision Therapy



Child History


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: YesNo
Last Visit Date: For What Reason? Is your child generally healthy?
Medications (including vitamins & supplements):
Allergies to Medications:
______________________________________________________________________________________________________________________________________________________

List significant illnesses, bad falls, high fevers or chronic illnesses:
Event/Condition...Age...Severity...Complications:
Event/Condition...Age...Severity...Complications:
______________________________________________________________________________________________________________________________________________________

Neuro/psych eval: YesNo By Whom?
Occupational Therapy eval? YesNo 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: ______________________________________________________________________________________________________________________________________________________

MED HX / SYSTEM REVIEW:

NOTICE OR COMPLAINS OF:   DOES CHILD HAVE OR HAD:
Eye turns in / out:YesNo***    Eye injury or surgery:YesNo***
Squints / Blinks a lot:YesNo    Lazy eye / Amblyopia:YesNo***
Covers / Closes one eye:YesNo    Patching:YesNo***
Lacks interest in looking at objects:YesNo***    Vision Therapy / Orthoptics:YesNo***
Rubs eyes excessively:YesNo    Surgery / Hospitalizations:YesNo
Reddened or encrusted eyelids:YesNo    Breathing problems:YesNo
Eyelid Droops:YesNo    Gastointestinal problems:YesNo
Poor tracking / eye movements:YesNo    Musculoskeletal problems:YesNo
Head tilt / Face turn:YesNo    Neurological problems:YesNo
Stumbles over objects / clumsy:YesNo    Development delayed:YesNo
Poor motor control:YesNo    Ear / Nose / Throat problems:YesNo
Head injury / trauma:YesNo

*** If yes, please complete strabismus / amblyopia tab.

______________________________________________________________________________________________________________________________________________________
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:lbs. and ozs.
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:YesNo Neurological:YesNo Psychological:YesNo
Occupational:YesNo Speech / Auditory:YesNo Physical:YesNo

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?
HeadachesBlurred Vision
Double VisionEyes "hurt" or "tired"
Nausea when doing visual tasksMotion Sickness / Car Sickness
Bothered by light / sun lightFrequent styes
Eyes itchEyes burn
Eyes tearEyes frequently reddened
Closing or covering one eyeLoses place while reading
Poor reading comprehensionWhen 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?


______________________________________________________________________________________________________________________________________________________

Strabismus/Amblyopia


(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:


TBI History

(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?


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























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


Dry Eye


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

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?

Reading/Computer


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













Dizziness/Motion Sensitivity


(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





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?