New Patient Forms

Name and Contact Information

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

Address:
City:	State/Zip Code	CO AL AK AZ AR CA 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 TX UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Simonson, Jennifer Dr. Dudley, Leanna Dr. Dowis, Roger	Guardians

Billing Information

- Is The Billing Address the Same?

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

Address

City	State	Zip Code
	CO AL AK AZ AR CA 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 TX UT VT VI VA WA WV WI WY

Home Phone:

Work Phone:

Medical History

Patient Visual and Health History

Preferred Name/Nickname:

Occupation or Grade in School:

Mother/Caretaker's Name (if patient is a child):

Father/Caretaker's Name (if patient is a child):

Referred by:

Main reason for the examination:

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Date of last eye exam:

Eye Doctor's Name/Office Name :

Results and recommendations from last eye exam:

What type of glasses or contact lenses do you own and/or wear?

Age when first prescribed glasses:

Do you have any other concerns or observations concerning your (or your child's) vision?
Please list specific issues you would like addressed:

Symptom Checklist:
Focusing difficulties

Blurred Vision at Near (Reading)Blurred Vision at Far DistancesFocus/Clarity goes in and outHolds reading too close or far
Vision is worse at the end of the dayFalling asleep when readingEyes "hurt" and feel tiredHeadaches
Difficulty copying from the boardDifficulty seeing details at night (driving)SquintingFrequent blinkingRubs eyes
Watery eyes (eyes tear up)Glare/Light sensitive

Comments on Focusing Difficulties (when do symptoms occur, how severe, what activities are affected etc.):

Eye alignment difficulties

Eye turns in, out, up, downCloses or covers an eyeDouble visionWords run together when readingUnable to judge distances
Clumsy/knocks things overPoor depth perceptionTilts or turns head to seeInconsistent sports performanceEyes drift
Difficulty with 3-D moviesPoor eye contact

Comments on Eye alignment difficulties (when do symptoms occur, how severe, what activities are affected etc.):

Tracking difficulties

Skipping lines when readingRepeating lines when readingSkips small words when readingReading comprehension declines over time
Poor reading comprehensionWords look like they move on the pageMoves head when readingUses a finger to keep spot
Loses place while readingDifficulty recognizing the same wordRemembers what is heard better than what is seenReads slowly
Rereads wordsPrefers being read toAvoids readingPoor trackingCan’t keep eye on ball

Comments on tracking difficulties (when do symptoms occur, current reading skill, how severe are symptoms, what activities are affected etc.):

Visual Processing difficulties
Difficulty seeing detailsConfuses letters, words, or numbersConfuses left and rightLoses attention easily
Poor test performanceForgetful, poor memoryMisplaces belongingsTakes a long time to complete assignmentsReverses letters/numbers
Difficulty with puzzlesCan't picture things in mind (visualize)
Comments on Visual Processing Difficulties (prior testing results, severity of difficulty, affect on performance etc.).? Please include information of any
other Sensory Processing delays or difficulties:

Eye-Hand Coordination difficulties

Writes uphill or downhillMisaligns columns or math problemsWrites slowlyFrequent erasingPoor writingPoor eye-hand coordination
Difficulty throwing a ballDifficulty catching a ballAvoids sportsPoor fine-motor: scissors/keys/toolsPoor large-motor skills: ex. bike riding

Comments on Eye-Hand Coordination Difficulties:

Eye health problems
Rubs eyesReddened or encrusted eyelidsEyelid droopsEyes sting or burnIrritated eyesEyes itch or feel gritty
Eyes become red or bloodshotFrequent styesFrequent pink eyeBothered by lighting (bright or dim)Nausea when doing visual tasks
Motion or car sickness

Comments on Eye health concerns:

History of Eye Disease

Poor Vision BlindnessEye injuryEye tumorEye surgeryHigh prescription glasses or contact lenses
Eye disease (Glaucoma, Cataract, etc.)

Please describe the details of the condition (onset, severity etc.): Do any eye health issues run in the family?

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Please complete this section if there is Amblyopia (lazy eye)

Amblyopia details (which eye, when diagnosed, family history etc.):

If prior patching was done, please comment on the patching details (how long per day, what eye, and type of patch).

If prior vision therapy or Orthoptics treatment was completed, please list the details (office name, doctor, treatment completed):

Please complete this section if there is Strabismus (crossed eyes/eyes drift out)

Strabismus details (which eye, age of onset, what direction, related to trauma or disease):

Prior treatment details: (surgery, eye drops, patching, glasses, vision therapy etc.)

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Medical History (list medical conditions, significant illnesses, bad falls, high fevers,
developmental delays or chronic illnesses.)

Please include health issues including general health, ear/nose/throat, heart, lung, stomach/GI,
muscles/bones, skin, nerves, anxiety/depression, blood, etc.

Medications (include vitamins and supplements) and for what health condition:

Please list any medical conditions that run in your family:

Allergies (include seasonal allergies, food allergies/sensitivities and allergies to medications):

Medical Doctor/Office Name:

Date and Reason for last doctor's visit:

Trauma/Surgery history:

Birth History:

Length of Pregnancy:

Pregnancy Complications:

Delivery/Neonatal Complications:

Birth weight:

?Apgar Scores:

Other Comments:

Biological AdoptedFoster

Were there any delays in development? (Crawling, walking, talking etc.)

Have any of the following evaluations been performed?
EducationalOccupational TherapyPhysical TherapyPsychologicalSpeech / Auditory
NeurologicalGenetic or Other:

IF YES, PLEASE LIST RESULTS AND RECOMMENDATIONS:

Is there any other information you feel would be helpful or important in our treatment?
(Relationships with peers/adults, reaction to stress, anxiety etc.)

Describe any school or work difficulties:

Any tutoring, IEP or 504 accommodations or remedial assistance?

Performing at potential?

Attitude towards school or work?? Attitude toward reading??

List leisure time activities (hobbies/sports/music/art etc.)

Sports performance: areas excelled in, areas of difficulty

Give a brief description of your self (or child) as a person:

Other notes for the Doctor: