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Patient information

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Billing information

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Chief Complaint

Eye History



Contact Lens Wearers only


Family Eye History


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Child History



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Medical History


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MED HX / SYSTEM REVIEW:






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Developmental History







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SKILLS / MILESTONES:







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VISUAL HISTORY:





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Strabismus / Amblyopia

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Brain Injury

What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?


Brain Injury Vision Symptom Survey

Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4



If you experience any of the symptoms below, please check if the symptom was present before the injury or only after:




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Dry Eye



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Reading and Computer Symptom Checklist


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.


Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4


Check All That Apply:



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Dizziness And Motion Sensitivity Checklist