New Patient Form

Demographics

Title First Last MI Suffix Nickname Race Mr. Mrs. Ms. Dr. Rev. Fr. Miss American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify

Address:		Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify	Preferred Language	English Spanish
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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Smoking Status	Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes)">Former smoker (no longer smokes)">Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Smoker (current status unknown) Unknown if ever smoked Other	Misc/Guardian

Height:

Ft.

In.

Weight:

Lbs.

Billing Information

Is The Billing Address the Same?

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

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:

COVID

COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition	Yes	No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For
Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based
On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19
Test Result Or Diagnosis, Or Have You Been Asked To Quarantine?

Please fill out the questionnaire below. If you do not know the answer to a question, feel free to leave it blank. Thank you!

Please list the names and dates of birth for other family members:

Spouse (if applicable):	Date of Birth:			Occupation:
Mother/Guardian (if minor):	Date of Birth:	Marital Status:	Married Separated Divorced Widowed Other	Occupation:
Father/Guardian (if minor):	Date of Birth:	Marital Status:	Married Separated Divorced Widowed Other	Occupation:
Child/Sibling (if minor):	Date of Birth:
Child/Sibling (if minor):	Date of Birth:
Child/Sibling (if minor):	Date of Birth:
Child/Sibling (if minor):	Date of Birth:

______________________________________________________________________________________________________________________________________________________

Were you referred to our office? Yes No

Whom may we thank for this referral?
If not referred, how did you hear about us?

______________________________________________________________________________________________________________________________________________________

VISUAL HISTORY:

Main reason for having an examination today:

Date of last evaluation:		Doctor's name:
Results/Recommendations:

Check all that apply.
I currently wear:

Glasses	- Wear Time:	Full-time	Part-time	If part-time, how often/when?
Contacts	- Wear Time:	Full-time	Part-time	If part-time, how often/when?	- Type:	Soft	Rigid Gas Permeable

Contact Lens Wearers: Are your lenses comfortable? No Yes Current Brand:
What solution do you use? What is your replacement schedule? Daily Weekly Every 2 weeks Monthly Quarterly Yearly How old is your current pair?
Do you use any eye drops (Rx or OTC)? Yes No If yes, please list name/how often used:

Do you have a history of any of the following?
	YES		NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Patching
Vision Therapy
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Other Eye Disease

Do you experience any of the following?
	YES	NO	If yes, when?
Headaches
Blurred Vision
Double Vision
Closing or covering one eye
Eyes "hurt" or "tired"
Nausea when doing visual tasks
Motion sickness / car sickness
Halos around lights
Bothered by light / sun light
Frequent blinking
Frequent styes
Eyes frequently reddened
Eyes itch
Eyes burn
Eyes tear
Eyes feel dry
Eyes feel sandy/gritty
Flashes
Floaters

If other eye disease was yes above, what disease? List any eye surgeries:
Describe any eye injuries:


Do you use a computer? YesNo If yes, how many hours a day? Any visual symptoms after using the computer? YesNo
If yes, describe those symptoms:

______________________________________________________________________________________________________________________________________________________

SYMPTOMS CHECKLIST:

Do you experience any of the following?

	YES	NO
Head close to paper when reading/writing
Avoid reading
Prefer being read to
Lose place while reading
Confuse letters or words
Reverse letters or words
Confuse right and left
Tire easily
Lose attention easily
Difficulty copying from board
When reading, letters/words appear to move or float around
Tilt head when reading/writing
Move head when reading
Skip, reread or omit words
Vocalize when reading silently
Read slowly
Use finger as a marker
Poor reading comprehension
Write or print poorly
Write neatly but slowly
Awkward or immature pencil grip
Frequent erasures

	YES	NO
Difficulty recognizing same word on different page
Difficulty with memory
Remember better hearing than seeing
Respond better orally than by writing
Know material, but do poorly on tests
Dislike/avoid near tasks
Poor large motor coordination
Poor fine motor coordination
Difficulty with scissors/small hand tools
Dislike/avoid sports
Difficulty catching/hitting a ball

Please describe any other visual symptoms not described above:

______________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY / REVIEW OF SYSTEMS:
Physician's Name: Last Visit Date: For What Reason?

List all medications you are currently taking and dosages (including any OTC/vitamins):


Do you have any allergies to medications? Yes No If yes, please list:

Ladies, are you pregnant or nursing?Yes No N/A If yes, what is the due/birth date?

List significant illnesses, high fevers, injuries, or hospitalizations, including date and any complications:


Has a neurological evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:


Has a psychological evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:


Has an occupational therapy evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:


Do you have, or ever had, any CHRONIC problems in the following areas?

	YES	NO
Neurological
Migraines
Seizures
Multiple Sclerosis
Endocrine
Diabetes
Thyroid problems
Ear/Nose/Throat
Allergies/Hay fever
Dry throat/mouth
Breathing problems
Asthma
Emphysema

	YES	NO
Cardiovascular
High blood pressure
Stroke
Gastrointestinal
Genitourinary
Musculoskeletal
Arthritis
Skin problems
Lymphatic/Hematological
Ear infections
Anemia
Cancer
Psychiatric disorder
Developmental delay
ADD/ADHD
Other

If you checked YES to any of these, please explain:

______________________________________________________________________________________________________________________________________________________

FAMILY HISTORY:

Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)?

	YES	NO	RELATIONSHIP TO PATIENT
Poor Vision
Blindness
Eye turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment/Disease

	YES	NO	RELATIONSHIP TO PATIENT
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Disease
Other Inherited Disease
If yes, what disease?

______________________________________________________________________________________________________________________________________________________

SOCIAL HISTORY:
This information is required by insurance carriers and is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. If so, check here:

	YES	NO	If yes, type/amt/how often?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?

Are you currently or have you ever been infected with:	YES	NO
Tuberculosis
Hepatitis
HIV
Syphilis
Chlamydia

______________________________________________________________________________________________________________________________________________________

Please fill out the questionnaire below. If you are filling this out for a child, all questions refer to the child. If you do not know the answer to a question, feel free to leave it blank. Thank you!

Please list the names and dates of birth for other family members:

Spouse (if applicable):	Date of Birth:			Occupation:
Mother/Guardian (if minor):	Date of Birth:	Marital Status:	Married Separated Divorced Widowed Other	Occupation:
Father/Guardian (if minor):	Date of Birth:	Marital Status:	Married Separated Divorced Widowed Other	Occupation:
Child/Sibling (if minor):	Date of Birth:
Child/Sibling (if minor):	Date of Birth:
Child/Sibling (if minor):	Date of Birth:
Child/Sibling (if minor):	Date of Birth:

______________________________________________________________________________________________________________________________________________________

Were you referred to our office? Yes No

Whom may we thank for this referral?
If not referred, how did you hear about us?

______________________________________________________________________________________________________________________________________________________

VISUAL HISTORY:

Main reason for having an examination today:

Date of last evaluation:		Doctor's name:
Results/Recommendations:

Check all that apply.
I currently wear:

Glasses	- Wear Time:	Full-time	Part-time	If part-time, how often/when?
Contacts	- Wear Time:	Full-time	Part-time	If part-time, how often/when?	- Type:	Soft	Rigid Gas Permeable

Contact Lens Wearers: Are your lenses comfortable? No Yes Current Brand:
What solution do you use? What is your replacement schedule? Daily Weekly Every 2 weeks Monthly Quarterly Yearly How old is your current pair?
Do you use any eye drops (Rx or OTC)? Yes No If yes, please list name/how often used:

Do you have a history of any of the following?
	YES		NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Patching
Vision Therapy
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Other Eye Disease

Do you experience any of the following?
	YES	NO	If yes, when?
Headaches
Blurred Vision
Double Vision
Closing or covering one eye
Eyes "hurt" or "tired"
Nausea when doing visual tasks
Motion sickness / car sickness
Halos around lights
Bothered by light / sun light
Frequent blinking
Frequent styes
Eyes frequently reddened
Eyes itch
Eyes burn
Eyes tear
Eyes feel dry
Eyes feel sandy/gritty
Flashes
Floaters

If other eye disease was yes above, what disease? List any eye surgeries:
Describe any eye injuries:


Do you use a computer? YesNo If yes, how many hours a day?
Screen time allowed for children per day: Hours on a tablet/near video game per day?
Hours on TV per day?
Any visual symptoms after using the computer? YesNo
If yes, describe those symptoms:

______________________________________________________________________________________________________________________________________________________

SYMPTOMS CHECKLIST:

Do you experience any of the following?

	YES	NO
Head close to paper when reading/writing
Avoid reading
Prefer being read to
Lose place while reading
Confuse letters or words
Reverse letters or words
Confuse right and left
Tire easily
Lose attention easily
Difficulty copying from board
When reading, letters/words appear to move or float around
Tilt head when reading/writing
Move head when reading
Skip, reread or omit words
Vocalize when reading silently
Read slowly
Use finger as a marker
Poor reading comprehension
Write or print poorly
Write neatly but slowly
Awkward or immature pencil grip
Frequent erasures

	YES	NO
Difficulty recognizing same word on different page
Difficulty with memory
Remember better hearing than seeing
Respond better orally than by writing
Know material, but do poorly on tests
Dislike/avoid near tasks
Poor large motor coordination
Poor fine motor coordination
Difficulty with scissors/small hand tools
Dislike/avoid sports
Difficulty catching/hitting a ball

Please describe any other visual symptoms not described above:

______________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY / REVIEW OF SYSTEMS:
Physician's Name: Last Visit Date: For What Reason?

List all medications you are currently taking and dosages (including any OTC/vitamins):


Do you have any allergies to medications? Yes No If yes, please list:

Ladies, are you pregnant or nursing?Yes No N/A If yes, what is the due/birth date?

List significant illnesses, high fevers, injuries, or hospitalizations, including date and any complications:


Has a neurological evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:


Has a psychological evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:


Has an occupational therapy evaluation been performed? Yes No If yes, by whom?
Results and Recommendations:


Do you have, or ever had, any CHRONIC problems in the following areas?

	YES	NO
Neurological
Migraines
Seizures
Multiple Sclerosis
Endocrine
Diabetes
Thyroid problems
Ear/Nose/Throat
Allergies/Hay fever
Dry throat/mouth
Breathing problems
Asthma
Emphysema

	YES	NO
Cardiovascular
High blood pressure
Stroke
Gastrointestinal
Genitourinary
Musculoskeletal
Arthritis
Skin problems
Lymphatic/Hematological
Ear infections
Anemia
Cancer
Psychiatric disorder
Developmental delay
ADD/ADHD
Other

If you checked YES to any of these, please explain:

______________________________________________________________________________________________________________________________________________________

FAMILY HISTORY:

Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)?

	YES	NO	RELATIONSHIP TO PATIENT
Poor Vision
Blindness
Eye turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment/Disease

	YES	NO	RELATIONSHIP TO PATIENT
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Disease
Other Inherited Disease
If yes, what disease?

______________________________________________________________________________________________________________________________________________________

SOCIAL HISTORY:
This information is required by insurance carriers and is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. If so, check here:

	YES	NO	If yes, type/amt/how often?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?

Are you currently or have you ever been infected with:	YES	NO
Tuberculosis
Hepatitis
HIV
Syphilis
Chlamydia

______________________________________________________________________________________________________________________________________________________

The following sections are for our child patients only. Adult patients may skip the remaining sections.

DEVELOPMENTAL HISTORY:
Length of Pregnancy: Type of delivery: Natural Caesarian Forceps / Vacuum used

During pregnancy of this child, did any of the following occur:
toxemiasmoking severe illness use of alcohol trauma use of drugs other
Please explain:

Child's birth weight: lbs. and oz.
Apgar score: @ birthafter 10 minutes
Please list all vaccinations child has received and date:

Any reactions to vaccinations? Yes No
If yes, please explain:


Was there ever any concern over your child's general growth or development? Yes No
If yes, why?


Did your child crawl (stomach on floor)? Yes No At what age?
Did your child creep (on all fours)? Yes No At what age?
At what age did your child walk?
Was child active? Yes No At what age?
Speech: First words:

Was early speech clear to others? Yes No
Is speech clear now? Yes No

______________________________________________________________________________________________________________________________________________________

SCHOOL:
Name of school: Grade: Teacher:
Address of school:
Age at time of entrance to: Pre-school: Kindergarten: First Grade:
Does your child like school? Yes No
Specifically describe any school difficulties:

Has your child changed schools often? Yes No
If yes, when and why?

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

Does your child seem to be under tension or pressure when doing school work? Yes No
Does your child have a 504 /IEP Plan for school? If yes, please explain reason and accommodations provided:

Has your child had any special tutoring, therapy, and/or remedial assistance?YesNo
If yes, when and how long?
Where and from whom?
Results:


Does your child like to read?YesNo
Does your child read for pleasure?YesNo
Overall schoolwork is: Above average Average Below average
Which subjects are:
Above average:
Average:
Below average:
Does your child spend a lot of time/effort to maintain this level of performance? Yes No
How much time does your child spend each day on homework?
To what extent do you assist your child with homework?
Do you feel your child is achieving up to potential? Yes No
Does the teacher feel your child is achieving up to potential? Yes No

______________________________________________________________________________________________________________________________________________________

GENERAL BEHAVIOR:
Are there any behavior problems at school? Yes No
If yes, what?

Are there any behavior problems at home? Yes No
If yes, what?



What is your child's reaction to fatigue?SagIrritableOther
What is your child's reaction to tension?AvoidanceIrritableOther
Does your child say and/or do things impulsively?YesNo
Is your child in constant motion?YesNo
Can your child sit still for long periods?YesNo
______________________________________________________________________________________________________________________________________________________

Please give a brief description of your child as a person:


Is there any other information you feel would be helpful/important in our treatment of your child?

______________________________________________________________________________________________________________________________________________________

Today's Date:    Are you currently working? Where?
Referred by:

MEDICAL HISTORY
Please Describe Your Injury / Accident In Your Own Words:

Have you or a family member been treated for any condition related to: Specifically, is there any history of the following:

Patient	If family, whom?
Eyes
Ears/Nose/Throat
Cardiovascular
Respiratory
Gastrointestinal
Psychiatric
Allergic/Immunologic
Neurological
Endocrine Disorder
Genitourinary
Skin
Musculoskeletal
Hematological/Lymphatic

Patient	If family, whom?
High Blood Pressure
Macular Degeneration
Thyroid Condition
Multiple Sclerosis
Brain Tumor
Traumatic Brain Injury
Glaucoma
Diabetes
Blindness
Strabismus
Amblyopia
Stroke
Other

Current Health Conditions:

Medications:

Drug Allergies:

Type of Injury/Accident:

Motor Vehicle

Fall

Blow to Head

Medication Related

Drug Abuse

Poison/Toxic Substance

Cord Around Neck

Industrial Accident

Carbon Dioxide

Stroke

Aneurysm

Hemorrhage

Concussion

Other:


Date(s) of Accident(s):



Motor Vehicle:
Speed of other object/vehicle: Speed of your vehicle: Where were you sitting? Driver Front Passenger Back Left Back Middle Back Right Other

What restraints were used? Lap Shoulder Car Seat Booster Seat Air Bag

Did your vehicle hit another object? Yes No If yes, where was your vehicle hit? Head On Rear Ended Toward Front Toward Rear Drivers Side Passenger Side Type of vehicle you were in:

Did you hit your head? Yes No If yes, on what?

Did other vehicle hit you? Yes No If other vehicles were involved, list type(s): Did you experience whiplash? Yes No

Toxic:

Type:

Please describe:

Anoxic:

Type:

Please describe:

Vascular:

Type:

Please describe:

Other:

Type:

Please describe:

Head Injury Description:

What part of your head was affected? Top of Head Right Side Forehead Face Left Side Back of Head
Were you unconscious? Yes No    If so, for how long?
Comments:


Initial Care:
Did you see a doctor concerning this accident? Yes No Whom did you see?
When/Where? Secondary Care Facility:
Tertiary/Home Care:


Subsequent/Other Professional Care:

What types of professional care have you received or are currently receiving?
Please select a doctor/therapist in the drop down menu:

Type of Doctor/Therapist:

Physician Psychiatrist Neurologist Neuro-psychologist Osteopathic Physician Physical/Vestibular Therapist Occupational Therapist Speech Therapist Psychologist/Psychiatrist Other

Name:

Date:

Results and Recommendations:

Type of Doctor/Therapist:

Physician Psychiatrist Neurologist Neuro-psychologist Osteopathic Physician Physical/Vestibular Therapist Occupational Therapist Speech Therapist Psychologist/Psychiatrist Other

Date:

Name:

Results and Recommendations:

Type of Doctor/Therapist:

Physician Psychiatrist Neurologist Neuro-psychologist Osteopathic Physician Physical/Vestibular Therapist Occupational Therapist Speech Therapist Psychologist/Psychiatrist Other

Date:

Name:

Results and Recommendations:

Type of Doctor/Therapist:

Physician Psychiatrist Neurologist Neuro-psychologist Osteopathic Physician Physical/Vestibular Therapist Occupational Therapist Speech Therapist Psychologist/Psychiatrist Other

Date:

Name:

Results and Recommendations:

Type of Doctor/Therapist:

Physician Psychiatrist Neurologist Neuro-psychologist Osteopathic Physician Physical/Vestibular Therapist Occupational Therapist Speech Therapist Psychologist/Psychiatrist Other

Date:

Name:

Results and Recommendations:

Type of Doctor/Therapist:

Physician Psychiatrist Neurologist Neuro-psychologist Osteopathic Physician Physical/Vestibular Therapist Occupational Therapist Speech Therapist Psychologist/Psychiatrist Other

Date:

Name:

Results and Recommendations:

Symptoms immediately following accident:

Double Vision

Headache

Loss of Memory

Blurred Vision

Pain in and around eyes

Vomiting

Dizziness

Restrictive field of view

Loss of balance

Disorientation

Flashes of light

Restricted motion

Comments:



Difficulties Following Accident:

A. Work Related - Please Describe:

B. Educational - Please Describe:

C. Recreational/Social/Hobbies - Please Describe:

D. Other - Please Describe:

E. Other Information Please take the time to share with us anything else that is relevant:

Visual History
Have you had a previous vision evaluation? Yes No Date:

Were glasses, contacts, or other optical devices recommended? Yes No If yes, what?
Are they used? Yes NoIf yes, when?
Doctor's Name/Address: Reason for Examination:
Were any tests, treatments, or therapies recommended? Yes No
If yes, results/recommendations:


Lifestyle
Is this new since the accident/injury? Yes No
Do you feel your vision interferes with activities of daily life? Yes No

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


Subsequent Symptoms/Experiences
(please select from the drop down menu)

Difficulty moving or turning eyes:	Was present before accident Had before accident and has worsened New symptom since accident
Blurred vision, distance viewing:	Was present before accident Had before accident and has worsened New symptom since accident
Pain when moving eyes:	Was present before accident Had before accident and has worsened New symptom since accident
Blurred vision, near viewing:	Was present before accident Had before accident and has worsened New symptom since accident
Wandering eye:	Was present before accident Had before accident and has worsened New symptom since accident
Slow to shift focus, near to far to near:	Was present before accident Had before accident and has worsened New symptom since accident
Double vision:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty taking notes:	Was present before accident Had before accident and has worsened New symptom since accident
Loss of place while reading:	Was present before accident Had before accident and has worsened New symptom since accident
Pulling or tugging sensation around eyes:	Was present before accident Had before accident and has worsened New symptom since accident
Pain in/around eyes:	Was present before accident Had before accident and has worsened New symptom since accident
Discomfort while reading:	Was present before accident Had before accident and has worsened New symptom since accident
Easily distracted:	Was present before accident Had before accident and has worsened New symptom since accident
Unable to sustain near work/reading:	Was present before accident Had before accident and has worsened New symptom since accident
Decreased attention span:	Was present before accident Had before accident and has worsened New symptom since accident
General fatigue while reading:	Was present before accident Had before accident and has worsened New symptom since accident
Reduced concentration:	Was present before accident Had before accident and has worsened New symptom since accident
Eyes get tired while reading:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty remembering what's been read:	Was present before accident Had before accident and has worsened New symptom since accident
Headaches:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty remembering formerly known objects:	Was present before accident Had before accident and has worsened New symptom since accident
Poor coordination:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty remembering info known in the past:	Was present before accident Had before accident and has worsened New symptom since accident
Dizziness:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty remembering people's names:	Was present before accident Had before accident and has worsened New symptom since accident

Difficulty remembering things seen:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty remembering names of objects:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty remembering things heard:	Was present before accident Had before accident and has worsened New symptom since accident
Clumsiness:	Was present before accident Had before accident and has worsened New symptom since accident
Difficulty remembering formerly known people:	Was present before accident Had before accident and has worsened New symptom since accident
Poor posture:	Was present before accident Had before accident and has worsened New symptom since accident
Get lost often:	Was present before accident Had before accident and has worsened New symptom since accident
Poor handwriting:	Was present before accident Had before accident and has worsened New symptom since accident
Disorientation:	Was present before accident Had before accident and has worsened New symptom since accident
Poor hand-eye coordination:	Was present before accident Had before accident and has worsened New symptom since accident
Covering/closing one eye:	Was present before accident Had before accident and has worsened New symptom since accident
Loss of balance:	Was present before accident Had before accident and has worsened New symptom since accident
Face turn:	Was present before accident Had before accident and has worsened New symptom since accident
Bothered by movement around you:	Was present before accident Had before accident and has worsened New symptom since accident
Head tilt:	Was present before accident Had before accident and has worsened New symptom since accident
Reduced depth perception:	Was present before accident Had before accident and has worsened New symptom since accident
Tunnel vision:	Was present before accident Had before accident and has worsened New symptom since accident
Abnormal general fatigue:	Was present before accident Had before accident and has worsened New symptom since accident
Restricted field of vision:	Was present before accident Had before accident and has worsened New symptom since accident
Bothered by being touched:	Was present before accident Had before accident and has worsened New symptom since accident
Floaters in field of view:	Was present before accident Had before accident and has worsened New symptom since accident
Bothered by noises around you:	Was present before accident Had before accident and has worsened New symptom since accident
Flashes of light:	Was present before accident Had before accident and has worsened New symptom since accident
"Curtain" billowing into field of view:	Was present before accident Had before accident and has worsened New symptom since accident
Light sensitivity:	Was present before accident Had before accident and has worsened New symptom since accident

Syntonics Questionnaire

1. Typical Diet/Appetite:

Diet Products / Soda

Junk Food

Good Fats

Cravings:

2. Energy level throughout the day:

3. Digestive System:

Diarrhea

Constipation

Bloating

Parasitic / Yeast

4. Psychological Health:

How Easy Is It For You To Relax

Bipolar

Depression

Anxiety

ADHD / ADD

5. Sleep Patterns:

6. Body Type:

7. Are you experiencing any pain throughout your body?

Submit Data

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