Online Patient Form for Non-Emergency Appointments


If you are experiencing, flashes, floaters, redness, or sudden loss of vision, call 505-341-2020 and press 3 to schedule an emergency appointment.


After completing all the applicable tabs, please click submit data on the final tab.

General


Patient Information
TitleFirstLastMISuffixPreferred Name
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
Primary Doctor Misc/Guardian
Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Ins

Primary
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision

Secondary
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Ins

Primary
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical

Secondary
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Child History


PLEASE COMPLETE THIS SECTION IF THE APPOINTMENT IS 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:

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:
______________________________________________________________________________________________________________________________________________________
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:

Other Allergies:


Have you, your child's teacher, babysitter, or other guardians noticed, or has your child complained of:
Headaches Blurred Vision Double Vision Eyes 'Hurt' or are 'Tired'
Eyes Itch Eyes Burn Eyes Tear Eyes Frequently Red
Frequent Styes Bothered By Light Loses Attention Easily Motion / Car Sickness
Closing / Covering One Eye Loses Place When Reading Nausea When Copmleting Visual Tasks
Poor Reading Comprehension When Reading, Letters / Words Appear To Move / Float Dizziness, 'Spinning' Sensation or Unbalance


Did these issues resolve? If yes, was it on it's own or by doctor intervention

______________________________________________________________________________________________________________________________________________________

Child has been diagnosed with: Yes / No Status When was the last instance if not current or chronic?
Allergies / Hay Fever Yes No Current
Behavioral Problems Yes No Current
Blood Disorder / Low Iron Yes No Current
Cancer Yes No Current
Depression Yes No Current
Developmental Problems Yes No Current
Diabetes (Insulin) Yes No Current
Diabetes (Non-Insulin) Yes No Current
Ear Infections Yes No Current
Head Injury / Trauma* Yes No Current
Heart Disease Yes No Current
Hepatitis Yes No Current
Herpes Zoster Yes No Current
High Blood Pressure Yes No Current
High Cholesterol Yes No Current
HIV Yes No Current
Low Blood Pressure Yes No Current
Lung Problems / Asthma Yes No Current
Multiple Sclerosis Yes No Current
Musculoskeletal Problems Yes No Current
Neurological Problems* Yes No Current
Seizures* Yes No Current
Sinus Yes No Current
Skin Rashes Yes No Current
Stroke* Yes No Current
Surgery / Hospitalizations* Yes No Current
Thyroid Disease Yes No Current
Tinnitus Yes No Current
Other Yes No Current
Other Yes No Current


Please use the space below to expand on any items marked yes above providing additional information such as complications that ocurred, severity of the illness or incident, what type of sugery, what bones were broken, and any other information that provides a more specific and detailed picture of your child's medical background. Please include events such as bad falls, high fevers, significant illness, even if they seem common


IF ANY OF THE STARRED ITEMS ARE MARKED YES, OR ANY OTHER SITUATION INVOLVING THE HEAD AND / OR SPINE, PLEASE FILL OUT THE HEAD TRAUMA TAB

______________________________________________________________________________________________________________________________________________________

Family History:

Family medical history is any important part of anyone's examination. Many disease and chronic conditions have genetic component. A knowledge of the family medical history can help spot possible issues early.
Family medical history is unknown due to a circumstance such as adoption
Disease / Condition / Illness Specific Type Is there a family history? If so, what is the relationship to the child?
Poor Vision
Strabismus  
Amblyopia  
Blindness  
Neurological
Learning Issues
Autoimmune Disease
Heart Disease
Blood Disorders / Low Iron
Diabetes
Seizures
Cancer
Other
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 birth weight:lbs. and oz.
Apgar score:@ birth after 10 minutes
My child is:
biological
adopted      At what age?
foster
other      Explain:

______________________________________________________________________________________________________________________________________________________
SKILLS / MILESTONES:

Did your child creep?(Stomach on floor) If yes, what age? Crawl? If yes, age? All fours? If not, please discribe:


The following activities have listed the average age for these milestones to be reached. Please use the drop down menu to select if the child reached these milestones early, average, late or if you are unsure when. Please remember these milestones can be reached dureing a wide range of time and the average is just somewhere in the middle of the range, being off of average is not an indicator of a problem on its own so please answer honestly.
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

First words at age: Was early speech clear to others? Is it clear now?
How is your child performing compared to others his/her age:

First words at age? Was speech clear to others? Is it clear now?


How well developed is your child's spoken vocabulary?

How much time does your child spend looking at a compute ror other electronic device? Does your child have behavior issues?


Has your child undergone any of the following testing/treatment/therapy?
Educational: Neurological: Psychological:
Occupational: Speech / Auditory: Physical:

If yes, please list all previous evaluations done on your child:


______________________________________________________________________________________________________________________________________________________

CURRENT STATUS

CONSTITUTIONAL:
Has your child had any issues with blood pressure, reacing heart, or feeling their pulse 'pounding'?
Has your child had any issues with their breathing?
Has your child had any fevers recently? If yes, what was the highest reading?
Has your child had any unexplained weight changes?
______________________________________________________________________________________________________________________________________________________

OPHTHALMOLOGIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Eye turns in or out Squints and/or blinks a lot Lacks interest in looking at objects
Rubs eyes excessively Covers or closes one eye often Reddened or encrusted eyelids
Eyelid Droops Tilting head and/or turning face Poor tracking or eye movements
Poor Motor Control Eyes hurt or tired Stumbles over objects or is clumsy
Headaches Blurred Vision Nausea when doing visual tasks
Double Vision Visible Stye Motion or car sickness
Watery Eyes Eyes feel dry, gritty, or 'burn' Difficulty or extreme dislike for reading


Has your child had any other complaints about their vision?
Have you, their teacher /babysitter / guardian noticed anything else concerning their vision?

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 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?
Have you ever been prescribed RESTASIS eye drops?

______________________________________________________________________________________________________________________________________________________

OTOLARYNGOLOGIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Feeling off balance Feeling dizzy Feeling like they've been spinning
Excessive Clumsiness Trouble Hearing Sound hurts ears
Ears feel full Nose feels full Pain behind eyebrows / deep in ears
______________________________________________________________________________________________________________________________________________________

RESPIRATORY:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Trouble catching breath - no activity Trouble catching breath post-active Trouble holding breath
Feeling of not getting enough air Hyperventilating  
______________________________________________________________________________________________________________________________________________________

GASTROINTESTINAL:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Nausea Stomach Pain Vomiting
Diarrhea Constipation Feeling of food being stuck
______________________________________________________________________________________________________________________________________________________

MUSCULOSKELETAL:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Legs seem unsteady Trouble extending leg fully Repeated twists of ankle
Knee / Hip pain Sitting hurts at times Trouble bending at waist
Pain in arms / wrists / shoulders Trouble reaching high Abnormal posture

has your child recently had a growth spurt?
______________________________________________________________________________________________________________________________________________________

INTEGUMENTARY:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Rashes Easily bruise Loose skin
Excessibly dry / flaky skin Feeling of bugs or skin Unexplained changes in skin color
______________________________________________________________________________________________________________________________________________________

NEUROLOGICAL:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Seizures Abnormal sleep cycle Fainting
Difficulty focusing / 'Daydreaming' Sudden change in coordination Change in speech (ie. slurring)
Smells scents not present Tingling (aka Pins Needles) Numbness of body parts
______________________________________________________________________________________________________________________________________________________

PSYCHIATRIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Excessive fears Anxious / Nervous Guiliting feelings (lots of 'Sorry')
Extreme mood swings Withdrawl from friend group Withdrawl from hobbies
Hallucinations Major change in eating habits Excessive anger / violence
______________________________________________________________________________________________________________________________________________________

HEMATOLOGIC / LYMPHATIC:
Have you, your child's teachers, babysitters, or other guardians noticed, or has your child complained of:
Bleeds excessively / Doesn't clot Wounds don't heal or heal slowly Excessive nosebleeds
Excessive bleeding from gums Swollen lymph nodes Recurring infections
______________________________________________________________________________________________________________________________________________________

Current grade in school: School:
What is their favorite subject?
Current special services: Prior special services: Age started kindergarten: Does your child like school?

In school work: Above averageAverageBelow average

Is your child working up to his/her potential?
Your feeling: Teacher's feeling:

What subjects are easy for your child?
What subjects are hard for your child?
Does your child like to read? Voluntarily? What types of books?
Has your child repeated a grade? If so, when?
Does your child have behavior problems at school? If yes, describe:


As part of the vision screening, we need to know how your child is doing in school. Please check the areas that apply to you child.

Averge reader
Slow/Fast reader
Dosen't enjoy reading
Perfers to be read to
Poor reading comprehension
Poor writing skills
Poor handwriting skills
Has letter/number reversals
Homework takes longer than it should
Struggles in school
Short attention span
Inconsistent or poor spots performance
Fine or gross motor skill difficulties
Avoids tasks that involve reading
Displays awkwardness and/or clumsiness
Confuses similar looking works
Misaligns numbers
Writes up or down on a slant
Complains of blurred vision
Needs to move when reading
Significant drop in grades in one year
Told that he or she has learning disability
Has headaches, nausea, or dizziness when reading
Honors curriculum
Regular classroom
Special education
Resource room
Tutor
Title 1 reading
Fatigued, frustraded, or stressed
Omits, inserts, or rereads letters and words
Has difficulty copying from the board
Nausea when doing close work
Difficulty spelling
Knocks over objects on a table
Other:

______________________________________________________________________________________________________________________________________________________

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?

Adult History


IF THIS APPOINTMENT IS FOR YOUR CHILD, YOU DO NOT NEED TO FILL OUT THIS TAB


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:

Please list any major suregeries you have had that aren't listed above:


VISION HISTORY
What is your primary type of vision correction? Glasses Contact Lenses Laser None
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:

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 Glaucoma
Retinal Detachment Implant Lens Left Eye Hypertensive Retinal Disease Diabetic Retinal Disease
Dry Eye Syndrome Amblyopia / Lazy Eye ** if yes, complete strabismus / amblyopia tab Strabismus / Wandering Eye ** if yes, complete strabismus tab

Other Eye Conditions:


______________________________________________________________________________________________________________________________________________________

SOCIAL HISTORY

How many hours per day do you work on a computer?

Do you drink alcohol? How often? Daily Weekly Monthly Few times a year Yearly

Do you smoke? How often do you go through an entire pack? Daily Weekly Monthly

Do you use recreational drugs? How often do you use? Daily Weekly Monthly Yearly

Do you hold religious beliefs that may dictate treatment?

Do you participate in any community groups? (ie. Scouts, Lodges, Lions Club, etc.)

What are your hobbies?

______________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY

Have you had a Neurological or Psychological evaluation?

Check here if currently pregnant.    How far along?

Do any of the following conditions apply to you?

Condition
Yes / No
Status When was the last instance if not current or chronic?
Allergies / Hay Fever Yes No Current
Alzheimer's Disease Yes No Current
Blood Disorder / Low Iron Yes No Current
Cancer Yes No Current
Depression Yes No Current
Diabetes (Insulin) Yes No Current
Diabetes (Non - Insulin) Yes No Current
Head Injury / Trauma* Yes No Current
Hearing Problems Yes No Current
Heart Disease Yes No Current
Hepatitis Yes No Current
Herpes Zoster Yes No Current
High Blood Pressure Yes No Current
High Cholesterol Yes No Current
HIV Yes No Current
Low Blood Pressure Yes No Current
Lung Problems / Asthma Yes No Current
Multiple Sclerosis Yes No Current
Musculoskeletal Problems* Yes No Current
Neurological Problems* Yes No Current
Parkinson's Disease Yes No Current
Rheumatoid Arthritis Yes No Current
Seizures* Yes No Current
Sinus Yes No Current
Skin Rashes Yes No Current
Stroke* Yes No Current
Thyroid Disease Yes No Current
Tinnitus Yes No Current
Other Yes No Current


Please use the space below to expand on any items marked yes above providing additional information such as complications that occurred, severity of the illness or incident. Please include events such as bad fails, high fevers, significant illnesses, any broken bones or minor surgeries?


IF ANY OF THE STARRED ITEMS ARE MARKED YES, OR ANY OTHER SITUATION INVOLVING THE HEAD AND/OR SPINE, PLEASE FILL OUT THE HEAD TRAUMA TAB.

______________________________________________________________________________________________________________________________________________________

CONSTITUTIONAL:
CURRENT STATUS


Have you had any issues with your blood pressure or elevated resting heart rate?

Have you had any issues with your breathing?

Have you had a fever recently? What was the highest reading?

Have you had any unexplained weight changes?

______________________________________________________________________________________________________________________________________________________

OPHTHALMOLOGIC:

Please check any of the following eye symptoms you are experiencing:
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 Other:


When you are reading or doing computer work do you experience eye strain? IF YES COPMLETE THE 'READING' TAB

Do you experience dizziness or motion sickness? IF YES PLEASE COMPLETE THE 'SYMPTOMS' TAB

The following relate specifically to a history of dry eye. Please mark any of these symptoms that you have experienced within the past week:
Glare Eye Ache Itching Redness Burning
Light Sensitivity Stinging Grittiness Dryness Dry Mouth
Tearing / Watery Eyes Mattering on your eyelids when you wake up in the morning
Night Driving Problems Eyelids swollen or red along the lash margin
Burning in the morning Artificial tear drops help, but do not last long enough
Decreased contact lens wearing time


do you take Omega-3 supplements daily?

Do you use Visine or other 'get the red out' drops?

Have you ever been prescribed RESTASIS eye drops?

Do you have any other complaints about your vision?

______________________________________________________________________________________________________________________________________________________

OTOLARYNGOLOGIC:

Are you experiencing any of the following ear, nose, and throat symptoms?

Feeling off balance Dizziness / Vertigo Excessive Clumsiness Trouble Hearing
Sensitivity to sounds Ears feel full / Muffled Sinuses / Nose feels full Pain behind eyes
Dry throat / mouth Post nasal drip Feeling like room is wobbling


______________________________________________________________________________________________________________________________________________________

CARDIOVASCULAR:

Are you experiencing any of the following heart related symptoms?

Heartburn Palpitations Feeling pulse throbbing Where?


______________________________________________________________________________________________________________________________________________________

RESPIRATORY:

Are you experiencing any of the following lung related problems?

Trouble catching breath - no activity Trouble catching breath post - active Touble holding breath
Feeling of not getting enough air Hyperventilating Pain in chest with breathing


______________________________________________________________________________________________________________________________________________________

GASTROINTESTINAL:

Are you experiencing any of the following stomach related symptoms?

Nausea Stomach Pain Vomiting
Diarrhea Constipation Feeling of food being stuck


______________________________________________________________________________________________________________________________________________________

MUSCULOSKELETAL:

Are you experiencing any of the following muscle and joint symptoms?

Legs seem unsteady Trouble extending leg fully Repeated twists of ankle
Knee / hip pain Sitting hurts at times Trouble bending at waist
Pain in arms / wrists / shoulders Trouble reaching high Abnormal posture


______________________________________________________________________________________________________________________________________________________

INTEGUMENTARY:

Are you experiencing any of the following skin symptoms?

Rashes Easily bruises Loose Skin
Excessively dry / Flaky skin Feeling of bugs on skin Unexplained changes in skin color
New moles / Marks on skin Unexplained bumps / Raised skin Unexplained change in skin texture


______________________________________________________________________________________________________________________________________________________

NEUROLOGICAL:

Are you experiencing any of the following symptoms?

Seizures Abnormal sleep cycle Fainting
Difficulty focusing / 'Daydreaming' Memory lapses Sudden change in coordination
Change in speach (ie. Slurring) Smells scents not present Fatigue
Tingling (aka Pins Needles) Where? Numbness of body parts Where?


______________________________________________________________________________________________________________________________________________________

PSYCHIATRIC:

Are you experiencing any of the following symptoms?

Excessive Fears Anxious / Nervous Guilt / Blame self for problems
Extreme mood swings Withdrawal from friends / Society Lack of interest in hobbies
Hallucinations Change in appetite / Eating habits Excessive anger / Violence
Lack of motivation for common tasks Paranoia Obsessive Thoughts


Have you experienced a traumatic event? When?
Briefly explain what happened? (ie. Loss of loved one, accident, close call, etc.)
Have you been diagnosed with PTSD?

______________________________________________________________________________________________________________________________________________________

HEMATOLOGIC / LYMPHATIC:

Are you experiencing any of the following symptoms?

Bleeds excessively / Doesn't clot Wounds don't heal or heal slowly Excessive nosebleeds
Excessive bleeding from gums Swollen lymph nodes Recurring infections


Lazy Eye


PLEASE ONLY COMPLETE THIS SECTION IF THE APPOINTMENT IS FOR LAZY EYE, EYE TURN, CROSSED OR WANDERING EYE


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:


Symptoms


COMPLETE THIS SECTION IF THE PATIENT HAS HAD ANY OF THE FOLLOWING INJURIES:

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

Headache
Nausea
Vomiting
Balance Problems

Nervous and Anxious
Feeling More Emotional
Numbness or Tingling

Dizziness (spinning or movement sensation)
Lightheadedness
Fatigue
Trouble Falling Asleep

Feeling Slowed Down
Feeling Like "in a fog"
Difficulty Concentrating

Sleeping More Than Usual
Drowsiness
Sensitivity To Light

Difficulty Remembering
Visual Problems
Slow Wavy Dizziness

Sensitivity To Noise
Irritability
Sadness and Hopelessness

Reminating Thoughts
Difficulty In Math, Science, Reading
Symptoms Worse At The End Of The Day
Difficulty With Attention
Difficulty Finding Words


If you experience any of the symptoms below, please check if the symptom was present before the injury, only after or both.
YesNo
Do busy environments cause you to have a headache, feel groggy, dizzy, anxious, tired? Ex: Lunchroom, grocery stores, hallways, etc.
Do you become dizzy when looking up/down, turning head, walking down busy hallways?
Do quick movement make you dizzy, anxious, foggy?
Do your symptoms worsen while traveling in the car?
Do you have blurred or fuzzy vision while reading?
Personal or family history of lazy eye or other ocular issues?
Do you feel frontal pressure in your head/ behind your eyes when engaged in reading/ computer work/ note taking?
Do you experience blurry or fuzzy vision while reading or have difficulty reading?
Are you having difficulties with "focus" or trouble with adjusting your eyes from near to far vision?
Do you feel your performance at school or work changed?
Ears ringing / Tinnitus
Are your symptoms worse during the week verses the weekend?
Are you excessively tired at the end of the day?
Bothered by noises
Do your difficulty turning off your thoughts?
YesNo
Do you become symptomatic when thinking about your symptoms?
Have your social activities been restricted?
Do you have difficulty falling asleep at night or other issues with sleep?
Personal history of migraines?
Do headaches occur w/ poor sleep?
Are headaches more likely to occur at the beginning of the week?
Does vision appear unstable or shift from eye to eye?
Portions of a page or objects appear to be missing
People or things suddenly appear unexpectedly from one side
Looking to the side of objects to see them better
Tunnel vision
Have you any neck pain or a history of neck injuries?
Have you had any symptoms that increase with change in neck position (static or dynamic)?
Have you experience any visual changes?
Have you had any episodes of dizziness or disequilibrium?
What activities can you no longer engage in due to your accident / injury?




Reading




CONVERGENCE IN SUFFICIENCY SYMPTOM SURVEY (CISS)

Please answer the following questions about how your eyes feel when reading or doing close work.
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 (not very often)=1 Sometimes=2 Fairly Often=3 Always=4

1. Do your eye 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?

In addition: Check all that apply

Tendency to close or cover one eye Reverses or forgets letters, numbers or words
Head tilt or movement Confuses similar looking words
Poor reading comprehension Difficulty recognizing the same word in the next paragraph
Head too close to the paper while reading or writing Poor spelling
Difficulty tracking moving objects, balls, etc... Poor visual-motor (eye-hand/foot) coordination
Writing is crooked or poorly spaced Confuses right and left
Misalignment of digits or columns of numbers Difficulty following a sequence of directions
Errors copying from chalkboard, computer or book Whispers when reading silently
Avoids near work or reading Comprehension decreases over time
Difficulty completing assignments in the time allotted Does not visualize

Dizziness and Motion Sensitivity Checklist




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

Submit Data



Please note that your health history is not reviewed until the day of the appointment.
If you have concerns that you feel require immediate attention, such as floaters, flashes, redness, or loss of vision please call 505-341-2020, extension 3 to schedule an emergency appointment.

Please click the button below to complete your online forms. Thank you!